Radiofrequency ablation for cancer pain with inadequate opioid response.

Data on the use of radiofrequency (RT) to ablate a tumor mass-causing pain have not been reported. A male in his 50s, diagnosed with a pelvic relapse of rectal cancer, was admitted for pain from the left groin to the perineum. The principal findings of contrast-enhanced computed tomography (CT) revealed the presence in the pelvic area of large solid tissue infiltrating the internal obturator muscle and eroding the vertebral column of the acetabulum. Also involving the gluteal muscles.He was poorly responsive to multiple opioids. He was treated with RT under CT guidance to ablate the pelvic mass. Pain relief was immediate as it was possible to reduce methadone doses since the afternoon of the operation day. Very selected patients who are not responsive to optimisation of opioid therapy, could be candidates to RF of the tumor mass, that may offer an efficient method to provide fast pain relief and allowing opioid dose reduction.

Inpatient deaths by medical service: characteristics in a comprehensive cancer centre.

AIM: To examine the intensity of care in the last 3 days of life in different medical settings of a comprehensive cancer centre. METHODS: In this retrospective study, the charts of patients who died in hospital from July 2019 to June 2023 were reviewed. The units taken into consideration were acute palliative care unit (APCU), oncology (ONC) and haematology (HEM), which included also the transplantation unit. Age, gender, diagnosis, Karnofsky or Eastern Cooperative Oncology Group, drugs used in the last 3 days of life, respiratory support, transfusion, parenteral nutrition, imaging studies, blood gas analysis, biochemistry, consultations and endoscopy were retrieved. RESULTS: Data on 177 patients who died in the period taken into consideration were reviewed. APCU was characterised by more frequent use of opioids, midazolam and scopolamine butylbromide. On the other side, HEM was characterised by higher use of vasoactive drugs, antibiotics, transfusions, imaging studies, growth factors, consultations, biochemistry, blood gas analysis, parenteral nutrition and ventilatory support. ONC was characterised by the larger use of anticoagulants and ventilatory support. CONCLUSION: A more aggressive treatment was performed in HEM, as denoted by a large use of life-sustaining treatments and investigations. Taken together, these data show that the way to die is different depending on the setting of care. End-of-life funnel is similar for every dying patient and choices should be based on short prognosis and expectation rather than on disproportionate and afinalistic treatments.

Methadone for Cancer Pain Management in Children: A Review of Literature.

Pain associated with cancer is a common feature among children and adolescents. Among opioids, methadone is a unique drug for its multiple mechanisms of action. Methadone is currently underutilized in children. The use of methadone for cancer pain management in children was assessed in a systematic review. Altogether, 141 children receiving methadone were examined, and another 126 children were assessed for QT prolongation. In the clinical studies, modalities of use, dosing, and duration of assessment were highly variable. In general, methadone was effective and well tolerated with a limited tendency for dose increases. QT prolongation was reported in a percentage of patients independently of the dosages or other variables. The majority of studies considered the use of methadone to be safe and effective in children. Despite methadone possessing interesting properties that make this drug unique in a pediatric context, data is limited, and the literature available is based on retrospective studies. Methadone could be an effective, inexpensive, and versatile medication in children with cancer who have pain. This drug deserves more interest and should prompt studies of better quality with a larger number of patients.

Revised European Association for Palliative Care (EAPC) recommended framework on palliative sedation: An international Delphi study.

BACKGROUND: The European Association for Palliative Care (EAPC) acknowledges palliative sedation as an important, broadly accepted intervention for patients with life-limiting disease experiencing refractory symptoms. The EAPC therefore developed 2009 a framework on palliative sedation. A revision was needed due to new evidence from literature, ongoing debate and criticism of methodology, terminology and applicability. AIM: To provide evidence- and consensus-based guidance on palliative sedation for healthcare professionals involved in end-of-life care, for medical associations and health policy decision-makers. DESIGN: Revision between June 2020 and September 2022 of the 2009 framework using a literature update and a Delphi procedure. SETTING: European. PARTICIPANTS: International experts on palliative sedation (identified through literature search and nomination by national palliative care associations) and a European patient organisation. RESULTS: A framework with 42 statements for which high or very high level of consensus was reached. Terminology is defined more precisely with the terms suffering used to encompass distressing physical and psychological symptoms as well as existential suffering and refractory to describe the untreatable (healthcare professionals) and intolerable (patient) nature of the suffering. The principle of proportionality is introduced in the definition of palliative sedation. No specific period of remaining life expectancy is defined, based on the principles of refractoriness of suffering, proportionality and independent decision-making for hydration. Patient autonomy is emphasised. A stepwise pharmacological approach and a guidance on hydration decision-making are provided. CONCLUSIONS: This is the first framework on palliative sedation using a strict consensus methodology. It should serve as comprehensive and soundly developed information for healthcare professionals.

Fast-track anesthesia and outcomes in hepatopancreatic cancer surgery: a retrospective analysis.

AIM: To assess the feasibility of a fast-track anesthesia protocol for hepatopancreatobiliary cancer surgery. METHODS: Retrospective analysis of consecutive sample of patients who underwent hepatopancreatic surgery for cancer for a period of 12 months in a high volume cancer center. Blended anesthesia was performed for most patients who were then observed in a recovery room area until achieving a safety score. RESULTS: Data of 163 patients were examined. Fifty-six and 107 patients underwent surgery for pancreatic cancer and liver surgery for primary tumor or metastases, respectively. Most patients were ASA 3. The mean durations of anesthesia and surgery were 322 min (SD 320) and 296 min (SD 133), respectively. Extubation was performed in the operating room in 125 patients. Post-operatory invasive ventilation was maintained in the recovery room in fifteen patients for a mean duration of 72.7 min (SD148.2). Only one patient was admitted to intensive care for 15 h. NIV was performed in three patients for a mean duration of 73.3 min (SD 15.3). The mean recovery room staying was 79 min (SD 80). The mean hospital postoperative stay was a mean of 8.1 days (SD 5.7). No complications were found in 144 patients. Globally, mortality rate was 3%. CONCLUSION: A program of fast-track anesthesia with a short stay in recovery room allowed to achieve a good outcome, limiting the costs of intensive care admission.

Pain Catastrophizing in Cancer Patients.

BACKGROUND: Pain catastrophizing is a group of negative irrational cognitions in the context of anticipated or actual pain. The aim of this study was to decipher the possible role of catastrophism on pain expression and outcomes after a comprehensive palliative care treatment. METHODS: A consecutive sample of patients with uncontrolled pain was assessed. Demographic characteristics, symptom intensity included in the Edmonton symptom assessment system (ESAS), and opioid drugs used were recorded at admission (T0). The Pain Catastrophizing Scale (PCS) was measured for patients. Patients were also asked about their personalized symptom goal (PSG) for each symptom of ESAS. One week after a comprehensive palliative care treatment (T7), ESAS and opioid doses used were recorded again, and the number of patients who achieved their PSG (PSGR) were calculated. At the same interval (T7), Minimal Clinically Important Difference (MCID) was calculated using patient global impression (PGI). RESULTS: Ninety-five patients were eligible. A significant decrease in symptom intensity was reported for all ESAS items. PGI was positive for all symptoms, with higher values for pain, poor well-being, and poor sleep. Only the rumination subscale of catastrophism was significantly associated with pain at T0 (B = 0.540; p = 0.034). CONCLUSIONS: Catastrophism was not associated with the levels of pain intensity, PSG, PSGR, and PGI for pain, except the rumination subscale that was associated with pain intensity at T0. A comprehensive palliative care management provided the relevant changes in symptom burden, undoing the pain expression associated with rumination.

Octreotide for long-lasting malignant bowel obstruction: two case reports.

BACKGROUND: Efficacy of the combination of octreotide and other drugs for the management of malignant bowel obstruction (MBO) has been well described. However, long-lasting stages with lack of stool emission are a challenging clinical condition of MBO that have never described. CASE DESCRIPTION: We describe two cases in which the addition of octreotide to supportive care measures, even given late after more than 3 weeks of no stool emission, resulted to be still effective in recovering the bowel transit. In the first case, a patient admitted to home palliative care had a nasogastric tube and reported to not have stool emission and passing gas for 25 days. Two days after starting the combination of octreotide and other drugs, the patient evacuated and the nasogastric tube was removed, without reporting nausea or episodes of vomiting. In the second case, a patient admitted to an acute palliative care unit, the patient had no stool emission for more than 3 weeks. A nasogastric tube was placed and comprehensive palliative care treatment was provided. Two days after starting a combination of octreotide and other drugs, the nasogastric tube was removed, without reporting vomiting. In both cases, bowel transit recovered and patients were able to initiate oral nutrition. CONCLUSIONS: The combination of octreotide with other drugs described for standard treatment for the management of MBO, should be attempted even in patients with very long periods of lack of feces emission.

Palliative Care Aspects in Multiple Sclerosis.

CONTEXT: Multiple sclerosis (MS) is an inflammatory, chronic, demyelinating, and neurodegenerative disorder of central nervous system, determined by an auto-immune dysfunction. Severe disability generally occurs in patients with progressive forms of MS that typically develop either after an earlier relapsing phase or less commonly from disease onset. Despite advances in research to slow the progression of MS, this condition remains a life-limiting disease with symptoms impacting negatively the lives of patients and caregivers. OBJECTIVES: To analyze the difefrent aspects of palliative cae in patients with MS. METHODS: To analyse selected literature assessing several palliative care aspects in patients with MS. RESULTS: People with MS have complex symptoms and different needs. These demands include how to deal with the burden of physical disability, how to organise daily life, restructuring social roles in the family and at work, keeping self-sufficiency in personal care, and preserving personal identity and community roles. CONCLUSION: An early palliative care approach aims to improve the palliative care skills and competencies of health professionals caring for the patients since the early stage of disease, including those who are actively undergoing disease-targeted therapies, rather than merely providing end-of-life care.

Opioid dose titration for cancer pain.

BACKGROUND: Opioid dose titration is a fundamental process of opioid therapy in cancer pain. AIMS: To assess data opioid dose titration. METHODS: The principal opioid dose titration methods, outcomes, and modalities of administration regarding the different opioid preparations were examined in different clinical contexts. RESULTS: Most studies suggested that opioid-naive patients should be started at doses of 15-30 mg/day of oral morphine equivalents. Opioid-tolerant patients may receive low or higher doses of oral morphine equivalents, depending on the level of opioid tolerance. Generally, dose increments of 30%-50% seem to be indicated to start dose titration. Some patients with severe excruciating cancer pain may present as an emergency requiring a rapid application of powerful analgesic strategies. The intravenous use of opioids may circumvent this problem providing a faster pain relief, due to the large availability and rapid achievement of effective plasma concentrations. DISCUSSION: Opioid dose titration is a delicate passage in patients with cancer pain. This approach may be different according to different clinical conditions. Opioid dose titration requires expertise to optimize cancer pain management while minimizing the development of adverse effects. CONCLUSION: While most approaches are meaningful and partially supported by existing literature, more studies are necessary to establish advantages and disadvantages in different clinical conditions. Optimization of opioid dose titration is of paramount importance. SIGNIFICANCE: This review provides the most recent insights on the different modalities of opioid dose titration in cancer pain management.

Mortality rate and palliative sedation in an acute palliative care unit.

AIM: To assess the mortality rate and the use of palliative sedation (PS) in an advanced long-standing acute palliative care unit (APCU) METHODS: The charts of patients who died and eventually received PS, consecutively admitted to the APCU for 4 years, were reviewed. Patients' characteristics and symptom intensity were recorded at admission, 3 days before death and the day before death (T0, T-3, T-end, respectively). For patients who were administered midazolam for PS, initial and final doses of drugs, as well as duration of PS until death, were recorded. RESULTS: One hundred and forty-eight patients died in APCU (8.9%), and 45 of them (30.4%) received PS. Younger patients and those reporting high levels of dyspnoea at T-3 and T-end were more likely to be sedated (p=0.002, p=0.013 and 0.002, respectively). The mean duration of PS was 27.47 hours. Mean initial and final doses of midazolam were 35.45 mg/day (SD 19.7) and 45.57 mg/day (SD 20.6), respectively (p=0.001). CONCLUSION: Mortality rate in APCU was very low. As a percentage of the number of deaths, PS rate was similar to that reported in other settings. PS does not seem to accelerate impending death.

Home palliative medicine: an audit of weekend and public holiday telephones on-call.

OBJECTIVES: To report the on-call activity of a well-established home care programme. METHODS: The charts of consecutive phone calls recorded in the weekend or public holidays were reviewed. RESULTS: The principal reason to call were based on caregivers' uncertainty, for the need of information or just to be reassured. The other more frequent reason to call was related to technical problems with peripheral intravenous central catheters. CONCLUSIONS: An integrated system of 'on call' allows to select the interventions, covering most of the patients' needs.

Opioid-induced Neurotoxicity in Patients with Cancer Pain.

OPINION STATEMENT: Opioid-induced neurotoxicity (OINT) is a neuropsychiatric syndrome observed with opioid therapy. The mechanism of OINT is thought to be multifactorial, and many risk factors may facilitate its development. If symptoms of OINT are seen, the prescriber should consider hydration, discontinuation of the offending opioid drug, or switching of opioid medication, or the use of some adjuvants. Multiple factors like inter- and intraindividual differences in opioid pharmacology may influence the accuracy of dose calculations for opioid switching. Experience and clinical judgment in a specialistic palliative care setting should be used and individual patient characteristics considered when applying any conversion table.

The Need of a Comprehensive Approach in a Condition of Poorly Opioid-Responsive Cancer Pain.

BACKGROUND: Spinal analgesia is often claimed as an effective strategy for patients with a poor response to systemic opioids. Despite the optimistic data reported in literature with intrathecal drug delivery systems (IDDS) for cancer pain, a critical analysis showed modest benefit. Indeed, intrathecal therapy may be potent means to be used in a very selected population. However, ability to manage spinal therapy combined with the use of opioids and other drugs in the general perspective of a comprehensive palliative care treatment may allow to resolve refractory cancer pain in a patient with a clinical profile of poor pain prognosis, according to the Edmonton staging system. METHODS: A long-term management of patients who underwent different therapeutic approaches, including multiple opioid lines, intrathecal analgesia, and a comprehensive palliative care treatment, is described. RESULTS: The case reported describes how the management of cancer pain may be complex, requiring a high level of expertise on using opioids, conversion ratios, different routes, particularly the intrathecal one, as well as providing a comprehensive palliative care treatment. CONCLUSIONS: No evidence-based treatment can be taken into consideration for such extreme conditions, where only experience and knowledge can guide to an effective course of treatment along a period of about six months. Timely therapeutic strategies are needed to be performed in each challenging clinical situation along the course of disease.

The Use of Parenteral Opioids in Cancer Pain Management.

Opioids should be offered to patients with moderate-to-severe pain related to cancer or active cancer treatment unless contraindicated. Although oral administration of opioids is generally preferable, a parenteral route may be advisable and mandatory in some clinical circumstances. Parenteral administration of opioids may accelerate the achievement of analgesia. The intravenous route fits the need of rapid achievement of analgesia in patients poorly responsive to other opioids and provides a fast analgesia in patients with breakthrough pain, that has a specific temporal pattern requiring a rapid analgesic effect. When the oral route is unavailable for the presence of nausea, vomiting, or dysphagia. the parenteral route is one of the principal options. Opioids have different pharmacokinetic and pharmacodynamic characteristics and should be chosen according to the individual needs. Thus, the knowledge and experience with these routes of administration are mandatory for anesthesiologists committed to cancer pain management.