The Evolution for the Treatment of Cancer Pain Syndromes Amitabh - - PowerPoint PPT Presentation

Amitabh Gulati, MD FIPP CIPS ASRA-PMUC Associate Attending, Director of Chronic Pain Program Director, Weill Cornell Pain Medicine Fellowship Memorial Sloan Kettering Cancer Center New York, NY, USA

The Evolution for the Treatment of Cancer Pain Syndromes

• Consultant for Medtronic, Flowonix, SPR Therapeutics, Nalu

Medical, and Bausch Health

• Advisor for AIS HealthCare

Financial Disclosures

• Brief introduction to primary cancer pain pathology
• Treatment related pain syndromes
• Chemotherapy and Immunotherapy
• Radiation
• Surgery
• Models for pain treatment options – the role of ultrasound
• An Ultrasound guided, Algorithmic Approach

Outline

Cancer Pain and Pharmacotherapy

• Pain – physical compression
• Nociceptive
• Visceral (e.g. pancreatic CA 

back pain)

• Musculoskeletal (e.g. bone

CA/metastasis)

• Neuropathic
• lumbar plexopathy from a

psoas mass

• Neurologic tumors

(schwannoma)

de Leon-Casasola OA, Cancer Control. 2000 Mar-Apr;7(2):142-8

• As of 2010 –
• Overall incidences are

decreasing (not breast CA)

• Overall mortality improving
• Now newer immunotherapies

are available

The cancer burden is changing

• chronic cancer pain conditions

Cho H Nat Can Ins Mono 2014 Mariotto AB Nat Can Ins Mono 2014

• Myeloma Bone Disease
• ↑Osteoclasts – cathespin

mediated bone resorption

• Decreased osteoblast activity
• Targeted pain therapies
• Nitrogen based bisphosphonates
• Receptor targets
• Proteosome inhibition-Bortezomib
• RANKL antagonists-denosumab

Pathophysiology of primary cancer pain: Bone Disease and Monoclonal Antibodies

Hameed A Canc Gr and Met 2014

Treatment related syndromes

• A chemotherapy dose limiting

toxicity

• IV Ketamine treatments
• DRG is a common target

Chemotherapy induced peripheral neuropathy

Brewer JR Gyn Onc 2015 Kim JH Jo Gyn Onc 2015

Immune checkpoint inhibitors

• Antibodies to
• CTLA-4 deactivate the

inhibition signal of T-cells

• PD-1 or PD-L1 activate anti-

tumor response of T-cells

• Have changed the course of

end-stage melanoma, renal cell and lung carcinoma

Spain L Cancer Treatment Reviews 2016

• Vascular and fibrotic phases
• Months to years after treatment

(e.g. RIBP)

• Incidence 2-3% per year
• Decreased to 1-2% with <55Gy
• Diagnosis of exclusion
• Cancer recurrence
• Schwannoma
• Other neurologic disease states
• Rx - Pentoxifyllin + tocopherol +

clondronate?

Radiation induced peripheral neuropathy

Delanian S Rad and Onc 2012

• Up to 50% incidence
• 3-18% severe pain
• Majority is scar related
• Surgical incision independent

even with VATS vs open thoracotomy

• Likely injury to intercostal

nerve

• Predictive factors
• Decreased in elderly
• Increased in females
• Diffuse noxious inhibitory

control

• Genetic variants of COMT and

Na channels

• Surgical technique reducing

nerve damage

Post-thoracotomy Pain Syndrome

Wildgaard K Eur J of CT Surg 2009

• Complex neural pathways of
• Intercostobrachial nerve
• Intercostal nerves
• Lateral and medial pectoralis

nerves

• Thoracodorsal nerve
• Long thoracic nerve
• Muscular pain and scarring
• Incidence 20-50%
• Associated poor quality of life
• Constellation of syndromes
• Phantom breast pain
• Intercostobrachial neuralgia
• Neuroma and scar
• Peripheral nerve injury (long

thoracic nerve etc)

Post-mastectomy pain syndrome

De Menezes Courceiro TC Rev Bras Anes 2009

Treatment paradigms

Biopsychosocial Model

Novy DM Crnt opin support pall care 2014

• Consider
• Anatomic model
• Discuss therapeutic options for

acute cancer pain syndromes

• Biopsychosocial model
• Reduce symptom burden during

the subacute phase

• Treating chronic cancer pain

syndromes

• While addressing palliative and

supportive care needs

• A treatment-based team

including

• Oncologists
• Interventional pain specialists
• Radiation oncologists
• Surgeons
• Typically neurosurgeons
• Radiologists
• Rehabilitation specialists

Anatomical Approach

Why Revisit Anatomical Approaches?

• Intercostal cryoneurolysis under ultrasound guidance

The Introduction of Ultrasound

Byas-Smith M, Gulati A A&A 2006

Regional Anesthesia

• Retrospective review
• N = 14498 (all major RA

blocks)

• PNS blocks N= 5436
• USG blocks N= 9062
• PNS
• 6 LAST
• ccurrences

1 nerve injury <12 mo.

• USG
• No reported occurrences
• 4 nerve injury 3< 12 mo
• In training anesthesiologists
• Observational study

Orebaugh et al. RAPM 2009 and update 2012

• Paravertebral block
• Field block

Take for example intercostobrachial nerve

• 28 males
• 1 mL of 2 % lidocaine

The Application of Ultrasound

Thallaj AK Saudi Med J 2015

Our approach to T2 paravertebral space

The Muscle Plane

Piracha M RAPM 2017

• 16 pre op patients scanned

for technique

• 10mL 0.5% bupivacaine
• 6 patients injected for lateral

chest wall, axilla, or medial arm persistent pain

Superficial serratus anterior plane

Wijayasinghe N Pain Phys 2016

Our approach to the superficial SA plane

Zocca J Pain Prac 2016

Ultrasound Guidance and Advanced Algorithms

Chest Wall Algorithm

Gulati A Pain Med 2015

Our illustrative cases

• RFA of the joint
• Sacroiliac joint and ligaments

injections

Lumbosacral metastatic disease

Hutson N Pain Med 2017

• Sacroiliac joint injections of

the ligamentous part between S1 and S2 with PSL as secondary target

• 2-3 injections over 3 months
• Reduction of sacroplasty to

almost nil.

Interesting Developments

Proximal joint injection for Sacral Fracture and Sacroiliac Metastasis

Oh D Pain Practice 2020

• Intrathecal drug delivery for

advancing disease

• Consider SCS trial for stable

neuropathic pain

Introduction of neuromodulation

Legler et al IPM Reports 2017

Thoracic Spinal Metastasis

Ultrasound guided thoracic targets

Rakesh e al. Pain Prac 2019

• A complicated pain syndrome
• Even since publication, we

have changed our paradigms.

Post-mastectomy pain

PMPS Algorithm 2020 N= 350

Yang A Pain Medicine (accepted in press)

• Please be safe everyone
• Any questions, please email me at gulatia@mskcc.org

Thank You