Outcome Studies Of Interpleural Analgesia In Cancer Pain

Interpleural analgesia may also be a useful addition to systemic analgesic medications in the treatment of moderate or severe cancer pain. There have been published reports of successful results from interpleural analgesic therapy for both nonmetastatic and metastatic cancers of the gastrointestinal tract, including the pancreas, kidney, breast, and lung; as well as lymphoma, sarcoma, histiocytoma, and myeloma.11" 1113 113 11531 11511 11551 11561 ™ This evidence describing the use of interpleural analgesia has primarily been in the form of case reports and case series. Using CT guidance, Waldman and colleagues1151 placed a subcutaneously tunneled, right-sided, interpleural catheter in a 33-year-old patient who had intractable abdominal pain secondary to colon cancer with extensive hepatic metastasis. After receiving 12-mL boluses of 0.5% bupivacaine administered every 8 hours, the patient experienced marked improvement of the pain with decreased opioid requirements, which lasted 6 weeks. Aguilar and colleagues1153 also reported success with long-term analgesia after placement of a subcutaneously tunneled catheter. Boluses of 20 mL of 0.375% bupivacaine with 1:200,000 epinephrine were injected every 6 hours over 1 months until the patient died.

Other clinicians have achieved success in treating intractable pain from malignancy with interpleural catheters that were not subcutaneously tunneled. Myers and colleagues1153 placed nontunneled, interpleural catheters in 10 patients with intractable pain secondary to a variety of metastatic cancers involving the breast, pancreas, kidney, and endometrium. After receiving either bolus injections or continuous infusions of interpleural bupivacaine, 9 of the 10 patients had minimal or no pain up to the time of death. Ramajoli and De Amid™ reported improved pain relief after a single bolus of interpleural bupivacaine in 8 patients with visceral pain secondary to metastatic pancreatic, renal, or gastric cancer. Amesbury and colleagues1153 used unilateral interpleural analgesia in 6 patients with intractable pain from metastatic disease involving the chest or abdomen. Good pain relief was observed with intermittent boluses or continuous infusion of bupivacaine in all 6 patients. One patient relapsed after 11 days, requiring an opioid infusion until death 2 days later.™ Similarly, others have also reported cases of successful pain relief with interpleural bupivacaine in patients with inoperable pancreatic carcinoma.1113 1153 Fineman™ provided excellent pain relief with interpleural bupivacaine for a patient with bronchogenic carcinoma metastatic to the chest wall and adjacent pleural region. Lastly, Dionne™ reported successful interpleural analgesia for malignant invasion of the brachial plexus. Interpleural injection of a neurolytic solution has been successfully used as an alternative to intermittent bolus or continuous infusion of interpleural local anesthetic solution. Lema and colleagues1153 reported excellent relief in a patient with intractable pain secondary to metastatic esophageal cancer by injection of phenol through an interpleural catheter.

Not all investigators have reported success with interpleural analgesia for the relief of intractable pain secondary to metastatic disease. Abraham1163 reported the inability to achieve adequate pain relief with interpleural analgesia in a case of metastatic mesothelioma, which may have been caused by tumor involvement of the pleural surfaces and a loculated pleural effusion.

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