Objective and subjective response in stage D2 prostate cancer patients with cancer pain

Fourty-eight patients with stage D2 prostate cancer, initially treated with endocrine therapy at the University of Tokyo between 1981 and 1990, were followed up and analysed. For the assessment of a subjective response, pain score, narcotic score, and performance stages (PS) were used. Of the fourty-eight patients, twenty-one suffered from cancer pain due to bone metastases. These patients showed significantly (p < 0.01) more lesions of bone metastases and higher PS, compared with patients without cancer pain. The progression free survival of these patients was significantly (p < 0.01) lower than that of patients without cancer pain, although the actuarial survival was not significant. In twenty-one patients with cancer pain, the objective and subjective response rates to endocrine therapy were 75% and 86%, respectively. The duration of pain relief was 1.25-54 (median 19) months. Those rates to anti-cancer chemotherapy in refractory patients (8 patients) previously treated with endocrine therapy were both 25% and those to additional administration of flutamide (FUL) or diethylstilbestrol (DES) in refractory patients (6 patients) were 33% and 100%, respectively. Although the duration of pain relief was 0.78-8 (median 2) months, the additional administration of DES or FLU led to pain relief and improved quality of life (QOL) in all 6 patients. Endocrine therapy such as LH-RH agonist and non-steroidal pure anti-androgen, which has no severe side effects, would be of great usefulness in stage D2 prostatic cancer patients with pain on the basis of efficacy and safety.(ABSTRACT TRUNCATED AT 250 WORDS)

Lumbar epidural blockade for management of pain in interstitial cystitis.

Thirteen patients with interstitial cystitis (IC), whose predominant symptom was pelvic or urethral pain, were treated with a series of lumbar epidural local anaesthetic blocks over an 18-month period. Response was evaluated by interview and with voiding diaries and visual analogue scales (VAS) for pain. Of the 55 injections given, immediate pain relief (lasting longer than 24 h) was obtained from 41 (75%). The duration of subsequent pain relief varied considerably, ranging from 2 to 75 days (mean 15.1). pain relief was accompanied by significant improvement in sleep habit and quality of life. A good correlation was noted between verbally expressed pain and the recorded VAS pain scores. Urinary frequency and average voided volumes were unaffected by treatment. Two patients failed to obtain any relief. Apart from minor transient backache at the injection site, there were no complications from the procedure. Lumbar sympathetic epidural blockade is an excellent means of providing pain relief in interstitial cystitis.

Radiotherapy of plantar heel spurs: indications, technique, clinical results at different dose concepts

BACKGROUND: In a retrospective study the efficacy of orthovoltage radiotherapy for refractory painful plantar heel spur was analyzed for 3 different radiation dose concepts. PATIENTS AND METHODS: From 1.1 1984 through 1.3.1994, 182 patients with refractory painful heel symptoms and radiologically proven plantar heel spur received radiotherapy. A total of 141 patients and 170 heels (due to double-sided symptoms) were completely documented in long-term follow-up. Clearly defined semi-quantitative criteria (9-point score) were used to analyze heel pain and ankle function prior to RT, 6 to 12 weeks post-radiation, and at last follow-up. The treatment outcome, i.e. (un)favourable response, of 3 radiation dose concepts were compared: Group A (n = 72 heels) received 12 Gy total radiation dose in 3 fractions per week and 2 series (6 x 1 Gy per series) separated by 6 weeks; group B (n = 98 heels) received 3 Gy total radiation dose in 10 fractions of 0.3 Gy (n = 50) or 5 Gy (10 x 0.5 Gy) (n = 48) with conventional fractionation in 1 series. RESULTS: Radiotherapy was very effective: at last follow-up 67% (group A) and 71% (group B) remained completely free of pain. The rate of "complete pain relief" (i.e. free of any pain symptoms) was not different between the 3 radiation concepts. However, significant differences were observed with regard to "incomplete or insufficient pain relief", i.e. a subjective pain relief of less than 80%, a delayed pain relief after more than 4 weeks or a relapse of pain symptoms in long-term follow-up. More favourable results were achieved in patients receiving 5 Gy or 12 Gy total dose, while patients with 3 Gy total dose had significantly worse results. Prognostic factors for "complete pain relief" were short duration of pain symptoms and acute pain symptoms prior to radiotherapy; with regard to "in-complete or insufficient pain relief" the total dose was found to be a prognostic parameter. CONCLUSIONS: Patients with refractory heel pain can yield a high response to radiotherapy even after failing various conventional treatments previously. Thus, radiotherapy should not be solely regarded as a last resort due to its low costs and high efficacy at low radiation doses.

Percutaneous alcoholization of the celiac plexus under echographic guidance: an alternative to splanchnicectomy? Study of 21 cases

Celiac plexus block is usually performed under fluoroscopic or tomodensitometric guidance. We report on a new procedure using sonographic guidance. The patient lies in supine position. We use a real-time sonograph (Kontron Sigma 1 AC) with a 3.5 MHz probe. On a transverse plane, the celiac axis is localized emerging from aorta. After local anesthesia, the tip of the spinal needle (177 mm, 22 G) is placed close to aorta (about 5 mm) on both sides. 10 to 15 ml of 1 per cent lidocaine then 10 to 15 ml of absolute alcohol are injected on each side. 21 patients (10 males, 11 females, mean age: 61) underwent the procedure. They presented with cancer of the pancreas in 14 cases, metastatic nodes in 3 cases, cholangiocarcinoma in 2 cases and chronic calcifying pancreatitis (CCP) in 2 cases. No pain relief occurred in 3 patients (14 per cent). On of those presented with CCP but the endoscopic cystic diversion of a small cyst was successful to eradicate pain. Partial pain relief occurred in 5 cases (24 per cent). Total pain relief was obtained in 13 cases (62 per cent). No complication related to the treatment was observed. Sonography is a simple and safe method of guidance to perform alcohol block of the celiac plexus. The anterior approach may prevent neurologic complications related to other methods of guidance.

Fetal oxygen saturation during epidural and paracervical analgesia.

BACKGROUND: We wanted to assess changes in fetal oxygenation during maternal epidural or paracervical analgesia in labor. METHODS: A prospective, open and non-randomized study. Twenty healthy parturients were enrolled before they asked for pain relief. Informed consent was obtained. Fetal and maternal oxygen saturations were measured before and up to 1 h after the initiation of analgesia. Fetal oximetry was performed with the Nellcor N-400 oximeter+FS-14B fetal oxygen sensor (Nellcor Puritan Bennett, Pleasanton, California, USA). Maternal oximetry was done with Datex Satlite portable monitor (Datex, Finland). Visual analog scale was used for assessing pain relief. Two-way analysis of variance and students t-test were used for statistical analyses. RESULTS: Fetal oxygenation initially improved in both groups. The saturation then returned to baseline in both groups. In the epidural group, the values remained at baseline or slightly below, while in the paracervical group the saturation remained a little higher than baseline (p=0.009). No change was seen in maternal oxygenation or heart rate. No change in fetal heart rate was found either. Epidural block was superior to paracervical block with respect to pain relief (p=0.002). CONCLUSIONS: There was a small but significant difference in fetal oxygenation between epidural and paracervical groups during the observation period. The magnitude of the difference is hardly clinically significant. A larger, randomized study is needed to elucidate the mechanisms behind this finding.

Single-needle celiac plexus block: is needle tip position critical in patients with no regional anatomic distortions?

BACKGROUND: The "single-needle" celiac plexus block is becoming a popular technique. Despite different approaches and methods used to place the needle, the success of the block depends on adequate spread of the injectate in the celiac area. In the present retrospective study, the influence of needle tip position in relation to the celiac artery on injectate spread was evaluated. METHODS: Among 138 cancer patients subjected, via an anterior approach, to computed tomography (CT)-guided single-needle neurolytic celiac plexus block, a radiologist, blinded to the aim of the study, retrospectively selected 53 cases with normal anatomy of the celiac area as judged by CT. The decision was based on images obtained before the block. Patients were then classified into either group A (29 patients), in whom the needle tip was caudad to the celiac artery, and group B (24 patients), in whom it was cephalad. To evaluate CT patterns of neurolytic (mixed with contrast) spread, the celiac area was divided on the frontal plane into four quadrants: upper right and left and lower right and left, as related to the celiac artery. Patient assessments by visual analog scale were reviewed to evaluate the degree of pain relief. pain relief 30 days after block was judged as long-lasting. The patterns of contrast spread in relation to the needle position and pain relief according to the number of quadrants with contrast were analyzed. RESULTS: The percentage of cases with four quadrants with contrast was higher when the needle tip was cephalad (58%, group B) than when it was caudad (14%, group A) to the celiac artery (P < 0.01). The percentage of patients with four and three quadrants with contrast was also higher in group B at 79% than in group A at 38% (P < 0.01). A significant difference in long-lasting pain relief was observed between patients with four quadrants with contrast (18 of 18, 100%; 95% confidence interval [CI], 81-100%) and patients with three quadrants with contrast (5 of 12, 42%; 95% CI, 15-72%) (P < 0.01). No patients showing two or one quadrant with contrast had long-lasting pain relief. CONCLUSIONS: These findings suggest that, when the celiac area is free from anatomic distortions, and the single-needle neurolytic celiac plexus block technique is used, the needle tip should be positioned cephalad to the celiac artery to achieve a wider neurolytic spread. It also appears that only a complete (four quadrants) neurolytic spread in the celiac area can guarantee long-lasting analgesia.

Cost-effectiveness of long-term intrathecal morphine therapy for pain associated with failed back surgery syndrome.

A decision analytic study was conducted using computer simulation to project the outcomes in a simulated cohort of patients whose treatment for back surgery had failed. The objective of this study was to estimate the direct cost of intrathecal morphine therapy (IMT) delivered via an implantable pump relative to alternative therapy (medical management) over a 60-month course of treatment. IMT administered by way of an implantable pump can provide effective pain relief for selected patients whose less invasive treatment modalities have failed. Previous research suggested that a pump implant is less costly than alternative methods providing comparable analgesia for treatment exceeding 12 to 18 months. However, those analyses did not include the cost of complications or pump replacement. Scenarios representing the course of IMT, devised by a panel of experts, were represented as treatment pathways in a Monte Carlo simulation. Adverse event rates were drawn from published data supplemented by expert judgment. Direct costs were based on a health insurer paid claims perspective (direct costs) discounted at a 5% annual rate. The cost-effectiveness of IMT was calculated based on a report of 65% to 81% "good to excellent" pain relief relative to alternative (medical) management. With both adverse event probabilities and costs set at most likely (base case) values, the expected total cost of IMT over 60 months was $82,893 (an average of $1382 per month). In a sensitivity analysis, the best case (low adverse event rate, low cost) estimate was $53,468 ($891/mo), whereas the worst case (high adverse event rate, high cost) estimate was $125,102 ($2085/mo). Cost-effectiveness estimates ranged from $7212 (best case) to $12,276 (worst case) per year of pain relief. Results from a computer simulation designed to collect the costs not included in previous empiric research indicate that IMT appears to be cost-effective when compared with alternative (medical) management for selected patients when the duration of therapy exceeds 12 to 22 months.

Pain problems in oncology

1. Not every cancer patient suffers from pain, but approximately 30-40% of regular inpatients and 60-70% in terminal stages do. 2. Not every pain syndrome in a cancer patient is tumor-derived: its role and potential cause need to be thoroughly investigated and treated. 3. Successful antineoplastic treatment is the best and most durable pain prophylaxis in advanced cancer patients. 4. Locally applicable pain treatments such as anesthesiologic, radiotherapeutic and surgical measures should be discussed on an interdisciplinary basis. 5. With chronic tumor pain and no further effect of antineoplastic and locally active treatments, pharmacologic analgesia is the most adequate method of effective pain relief. 6. Prophylactic prescription of effective analgesics in adequate doses and at regular intervals, according to accepted "pain-ladders", is the most successful method of effective and lasting pain relief. 7. Public and medical bias against adequate use of oral opiates in chronic cancer pain must be overcome. 8. Effective pain relief leads to improvement of life quality as well as social reintegration of late stage cancer patients. 9. The influence of psychosocial variables on pain perception and the outcome of analgesia should not be underestimated.

Personal control in pain relief during labour.

Personal control is a central feature of women's involvement in their childbirth experiences. To achieve this control tacit rules and guidelines are applied to define how women and the professionals who care for them should behave. This study investigated the extent to which women exercised control in pain relief during the first stage of labour by comparing (a) the rules which they held prior to childbirth (2-3 cm cervical dilatation) with those which they afterwards felt applied to their labour and (b) the rules held by the women before and after childbirth with those held by the midwives. In a quantitative study using a repeated measures design, a questionnaire was administered to 35 midwives and to 100 women prior to and within 24 hours following their delivery. Consistency of the women's scores before and after childbirth, indicated by few statistically significant differences, tended to confirm their rules on control of pain relief. Some of the rules were held even more strongly following childbirth. A surprising finding was the even stronger agreement by midwives with some of the rules. There was a definite trend for many of the rules held by the women prior to childbirth to increase following birth towards those of the midwives. This could be the result of the experience of childbirth per se but the possibility that it was contributed to by the influence of the midwives cannot be ruled out and warrants further research. An interesting hierarchy in the rules for compliance with professional care has been highlighted.

Percutaneous vertebroplasty--a new method for alleviation of back pain

Percutaneous vertebroplasty (PV) is an interventional radiological procedure for the treatment of pain in patients with vertebral compressions caused by osteoporosis, metastases or hemangioma. The method was introduced by Professors P Galibert and H Deramond at the University Hospital of Amiens, France in 1984. It consists of percutaneous injection of bone cement (polymethylmethacrylate) into the vertebral body under fluoroscopy guidance. PV has proved to be effective and safe. Permanent complete or partial pain relief is obtained within hours or days in more than 90% of cases. The complication rate is low, less than 3% for patients with osteoporosis and up to 10% in patients with metastases. We report on the first 17 patients (11 with osteoporosis, 3 with metastases and 3 with hemangiomas) treated in Sweden at the Department of Interventional Neuroradiology, Sahlgrenska Hospital, Goteborg University. We obtained complete pain relief in 71% and partial pain relief in 17% of cases. The majority of the patients improved in mobility and quality of life. We had no clinical complications.