Palliative care

For cancer patientsTeam approach

Sympathy is not enough

What can we do ?

Better quality of life

Cancer pain management

Dr. Ahmed Helmy Abouel SoudBoard member of WSPC

Professor of Pain Relief, N.C.I., Cairo University, Egypt

Cancer pain

• 70 % of advanced cases• Any site & any type

Tools

• Drugs • Interventions

Pharmacotherapy

• WHO ladder system• By the clock • Oral or transdermal rout • Full dose

WHO ladder system

• Non opioid ± adjuvants• Weak opioids + I• Strong opioids + I

Sustained release opioids

• Oral weak opioids e.g. tramundine, D.H.C.

• Oral strong opioids e.g. MST, oxycontin and MXL

• Transdermal e.g. Fentanyl patch (Durogesic)

Newer Fentanyl (Durogesic) patch

• Simpler, thinner• Better adhesion• Fentanyl in dissolved

state with no ethanol as permeation enhancer

• Can be divided • Guarantee stable

blood fentanyl level for 72 h

Side effects

Pain interventions

minimally invasive procedures

• Delivery of opioids to the C.N.S.

• Destruction of pain pathway

Delivery of opioids to the C.N.S.

• Frequent delivery by special device• Generalized pain, initial good response to

the systemic drug with appearance of tolerance or side effects, adequate test response

• Better response with lower dose and lesser side effects

Pain pathway destruction

• Advanced cancer• Localized severe

pain• Accessible target

Ideal procedure

• Life long• High success rate with selective destruction • Complete or satisfactory pain relief• Percutaneous by R.F. or neurolytics • Under local anesthesia • No or minimal morbidity

Common targets

• Celiac plexus• Superior hypogastric

plexus• Ganglion impar • Posterior root• Spinothalamic tract• Trigeminal tract &

nucleus

Neurolytic procedures

• Celiac plexus• Superior hypogastric plexus• Ganglion impar • Posterior root

Celiac plexus destruction

Upper abdominal visceral pain

Pancreas, hepatobiliary, stomach, intestine

85% success

Celiac Plexus

Superior hypogastric plexus destruction

• Pelvic visceral pain• Bladder, prostate,

cervix, uterus, ovary, colon& rectum

• 75% success

Ganglion impar

• Junction of the two paravertebral sympathetic chains

• Sacroccygeal junction• SMP at the perineal region • Ca rectum, anal canal, vagina& vulva• 50-60% success

Posterior (sensory) root

• Localized somatic• Rib metastases, ca

rectum & anal canal• 70% success• Sensory loss

Percutaneous RF procedures

• Cordotomy

• Tractotomy-nucleotomy

• Spinothalamic tract

• Trigeminal tract & nucleus

Spinothalamic tract

• Crossed fibers• Anterolateral

quadrant • Pain & temperature• Somatotopic

organization• Important relations

Cordotomy

• Unilateral cancer pain below the clavicle

• Lung, pleura, pelvic bones & muscles, upper & lower limb

• 95% success• Loss of pinprick &

temp

Descending trigeminal tract & subnucleus caudalis

• Posterolateral part• Joined by VII, IX and X• Somatotopic organization• Important relations• Pain & temperature

Trigeminal Tractotomy-Nucleotomy

• Percutaneous • under L.A. & sedation• C-T guided• R.F. • Occiput / C1 level • 75 % success

Can we offer this ?