Stereotactic Radiosurgery Hypophysectomy for Palliative Treatment of Refractory Cancer Pain: A Historical Review and Update

Medically refractory pain in those with advanced cancer significantly reduces one’s quality of life. Therefore, palliative interventions to mitigate cancer pain and reduce opioid requirements are necessary to reduce patient suffering and opioid-induced side effects. Hypophysectomy, a largely forgotten pain procedure with several technical variations, has been repeatedly studied in small series with encouraging results, though historically has been fraught with complications. As a result, the minimally invasive and more tolerable stereotactic radiosurgery (SRS) hypophysectomy has resurfaced as a possible treatment for cancer-related pain. While the mechanism of pain relief is not entirely understood, the hypothalamohypophyseal axis appears to play an essential role in pain perception and transmission and involves C fiber signal processing and downstream modulation of the brainstem and spinal cord via the hypothalamus. This review highlights the role of hypophysectomy in alleviating advanced cancer pain, both in hormonal and nonhormonal malignancy and the current mechanistic understanding of pain relief for the three primary hypophysectomy modalities used historically: surgical and chemical adenolysis, as well as the more recent, SRS hypophysectomy. Given the lack of high-quality evidence for stereotactic radiosurgery hypophysectomy, there is a need for further rigorous and prospective clinical studies despite its ideal and noninvasive approach.

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Role of Ethnicity on Pain Perception, Fatigue, and Quality of Life in a Pediatric Chronic Pain Population

PsycEXTRA Dataset ◽

10.1037/e691752007-001 ◽

2007 ◽

Author(s):

Jeffrey I. Gold ◽

Trina Haselrig ◽

D. Colette Nicolaou ◽

Katharine A. Belmont

Keyword(s):

Quality Of Life ◽

Chronic Pain ◽

Pain Perception ◽

Pediatric Chronic Pain

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Cancer pain management

Orvosi Hetilap ◽

10.1556/oh.2014.29808 ◽

2014 ◽

Vol 155 (3) ◽

pp. 93-99

Author(s):

Péter Heigl

Keyword(s):

Quality Of Life ◽

Pain Management ◽

Pain Relief ◽

Life Expectancy ◽

Cancer Pain ◽

Cancer Pain Management ◽

Medical Activity ◽

Short Summary ◽

Adequate Quality

Pain is a significant and alarming symptom of cancer seriously affecting the activity and quality of life of patients. Recent research proved that inadequate analgesia shortens life expectancy. Therefore, pain relief is not only a possibility but a professional, ethical and moral commitment to relieve patients from suffering, as well as ensure their adequate quality of life and human dignity. Proper pain relief can be achieved with medical therapy in most of the cases and the pharmacological alternatives are available in Hungary. Yet medical activity regarding pain relief is far from the desired. This paper gives a short summary of the guidelines on medical pain management focusing particularly on the use of opioids. Orv. Hetil., 2014, 155(3), 93–99.

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Impact of individualized management of breakthrough cancer pain on quality of life in advanced cancer patients: CAVIDIOPAL study

Supportive Care in Cancer ◽

10.1007/s00520-021-06006-1 ◽

2021 ◽

Author(s):

Albert Tuca Rodríguez ◽

Miguel Núñez Viejo ◽

Pablo Maradey ◽

Jaume Canal-Sotelo ◽

Plácido Guardia Mancilla ◽

...

Keyword(s):

Quality Of Life ◽

Cancer Pain ◽

Advanced Cancer ◽

Low Doses ◽

Breakthrough Cancer Pain ◽

Eortc Qlq C30 ◽

Eortc Qlq ◽

Individualized Management ◽

The Impact

Abstract Purpose The main aim of the study was to assess the impact of individualized management of breakthrough cancer pain (BTcP) on quality of life (QoL) of patients with advanced cancer in clinical practice. Methods A prospective, observational, multicenter study was conducted in patients with advanced cancer that were assisted by palliative care units. QoL was assessed with the EORTC QLQ-C30 questionnaire at baseline (V0) and after 28 days (V28) of individualized BTcP therapy. Data on background pain, BTcP, comorbidities, and frailty were also recorded. Results Ninety-three patients completed the study. Intensity, duration, and number of BTcP episodes were reduced (p < 0.001) at V28 with individualized therapy. Transmucosal fentanyl was used in 93.8% of patients, mainly by sublingual route. Fentanyl titration was initiated at low doses (78.3% of patients received doses of 67 μg, 100 μg, or 133 μg) according to physician evaluation. At V28, mean perception of global health status had increased from 31.1 to 53.1 (p < 0.001). All scales of EORTC QLQ-C30 significantly improved (p < 0.001) except physical functioning, diarrhea, and financial difficulties. Pain scale improved from 73.6 ± 22.6 to 35.7 ± 22.3 (p < 0.001). Moreover, 85.9% of patients reported pain improvement. Probability of no ≥ 25% improvement in QoL was significantly higher in patients ≥ 65 years old (OR 1.39; 95% CI 1.001–1.079) and patients hospitalized at baseline (OR 4.126; 95% CI 1.227–13.873). Conclusion Individualized BTcP therapy improved QoL of patients with advanced cancer. Transmucosal fentanyl at low doses was the most used drug. Trial registration This study was registered at ClinicalTrials.gov database (NCT02840500) on July 19, 2016.

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The use of fentanyl in pain management in head and neck cancer patients: a narrative review

British Journal of Pain ◽

10.1177/2049463717736787 ◽

2017 ◽

Vol 12 (3) ◽

pp. 155-162 ◽

Cited By ~ 5

Author(s):

Raffaele Giusti ◽

Paolo Bossi ◽

Marco Mazzotta ◽

Marco Filetti ◽

Daniela Iacono ◽

...

Keyword(s):

Cancer Pain ◽

Head And Neck ◽

Relative Effectiveness ◽

Malignant Tumours ◽

Exclusion Criteria ◽

Search Terms ◽

Strong Opioids ◽

Cross Reference

Background: Head and neck (H&N) cancers account for about 5% of all malignant tumours. Pain is one of the most feared consequences of H&N neoplasms and is experienced by up to 80% of patients and worsens their quality of life inhibiting speaking, eating, drinking or swallowing. Nevertheless, pain is still often underestimated and undertreated. Objectives: The role of opioids in cancer pain has been well established but evidences about the role and the relative effectiveness of opioids such as fentanyl in the context of H&N cancer pain remains unclear. Methods: A literature review based on the guidance of the Centre for Reviews and Dissemination was conducted. An iterative approach was used starting with an electronic search in the MEDLINE database. The search terms ((‘Neoplasms’[Mesh]) AND ‘Head and Neck Neoplasms’[Mesh]) AND ‘Fentanyl’[Mesh] were used. Results: A total of 18 publications were found by the first performed search on PubMed. Other publications concordant with our aim were found by cross-reference. Considering inclusion and exclusion criteria for our review, eight papers resulted eligible for analysis. Conclusion: Fentanyl transdermal therapeutic system (TTS) seems to be an important option, thanks to the way of administration, the good safety and tolerability profiles to control baseline pain. For breakthrough cancer pain (BTcP), several formulations of transmucosal fentanyl are available. All the formulations seem to be active and safety but we lack head-to-head studies of fentanyl versus other strong opioids, as well as with different formulation of fentanyl, particularly for BTcP where H&N cancer population is very poorly represented.

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A Prospective Multicentre Study to Evaluate the Efficacy and Tolerability of Osmotic Release Oral System (Oros®) Hydromorphone in Opioid-Naive Cancer Patients: Results of the Korean South West Oncology Group Study

Pain Research and Management ◽

10.1155/2015/458389 ◽

2015 ◽

Vol 20 (6) ◽

pp. 293-299 ◽

Cited By ~ 3

Author(s):

Eun-Kee Song ◽

Hyunjeong Shim ◽

Hye-Suk Han ◽

DerSheng Sun ◽

Soon-Il Lee ◽

...

Keyword(s):

Quality Of Life ◽

Pain Relief ◽

Cancer Pain ◽

Pain Intensity ◽

Cancer Patients ◽

Pain Control ◽

Intensity Difference ◽

Front Line ◽

Long Acting

BACKGROUND: Osmotic release oral system (OROS®) hydromorphone is a potent, long-acting opioid analgesic, effective and safe for controlling cancer pain in patients who have received other strong opioids. To date, few studies have examined the efficacy of hydromorphone for pain relief in opioid-naive cancer patients.OBJECTIVES: A prospective, open-label, multicentre trial was conducted to determine the efficacy and tolerability of OROS hydromorphone as a single and front-line opioid therapy for patients experiencing moderate to severe cancer pain.METHODS: OROS hydromorphone was administered to patients who had not previously received strong, long-acting opioids. The baseline evaluation (visit 1) was followed by two evaluations (visits 2 and 3) performed two and 14 weeks later, respectively. The starting dose of OROS hydromorphone was 4 mg/day and was increased every two days when pain control was insufficient. Immediate-release hydromorphone was the only accepted alternative strong opioid for relief of breakthrough pain. The efficacy, safety and tolerability of OROS hydromorphone, including the effects on quality of life, and patients’ and investigators’ global impressions on pain relief were evaluated. The primary end point was pain intensity difference (PID) at visit 2 relative to visit 1 (expressed as %PID).RESULTS: A total of 107 patients were enrolled in the present study. An improvement in pain intensity of >50% (≥50% PID) was observed in 51.0% of the full analysis set and 58.6% of the per-protocol set. The mean pain score, measured using a numerical rating scale, was significantly reduced after two weeks of treatment, and most adverse events were manageable. Quality of life also improved, and >70% of patients and investigators were satisfied with the treatment.CONCLUSIONS: OROS hydromorphone provided effective pain relief and improved quality of life in opioid-naive cancer patients. As a single and front-line treatment, OROS hydromorphone delivered rapid pain control.

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An Open-Label, Analgesic Efficacy and Safety of Pituitary Radiosurgery for Patients With Opioid-Refractory Pain: Study Protocol for a Randomized Controlled Trial

Neurosurgery ◽

10.1093/neuros/nyx363 ◽

2017 ◽

Vol 83 (1) ◽

pp. 146-153 ◽

Cited By ~ 2

Author(s):

Pierre-Yves Borius ◽

Stéphanie Ranque Garnier ◽

Karine Baumstarck ◽

Frédéric Castinetti ◽

Anne Donnet ◽

...

Keyword(s):

Quality Of Life ◽

Pain Relief ◽

Cancer Pain ◽

Controlled Trial ◽

Analgesic Efficacy ◽

Standards Of Care ◽

Control Group ◽

Efficacy And Safety ◽

Open Label

Abstract BACKGROUND Hypophysectomy performed by craniotomy or percutaneous techniques leads to complete pain relief in more than 70% to 80% of cases for opioid refractory cancer pain. Radiosurgery could be an interesting alternative approach to reduce complications. OBJECTIVE To assess the analgesic efficacy compared with standard of care is the primary goal. The secondary objectives are to assess ophthalmic and endocrine tolerance, drug consumption, quality of life, and mechanisms of analgesic action. METHODS The trial is multicenter, randomized, prospective, and open-label with 2 parallel groups. This concerns patients in palliative care suffering from nociceptive or mixed cancer pain, refractory to standard opioid therapy. Participants will be randomly assigned to the control group receiving standards of care for pain according to recommendations, or to the experimental group receiving a pituitary GammaKnife (Elekta, Stockholm, Sweden) radiosurgery (160 Gy delivered in pituitary gland) associated with standards of care. Evaluation assessments will be taken at baseline, day0, day4, day7, day14, day28, day45, month3, and month6. EXPECTED OUTCOMES We could expect pain improvement in 70% to 90% of cases at day4. In addition we will assess the safety of pituitary radiosurgery in a vulnerable population. The secondary endpoints could show decay of opioid consumption, good patient satisfaction, and improvement of the quality of life. DISCUSSION The design of this study is potentially the most appropriate to demonstrate the efficacy and safety of radiosurgery for this new indication. New recommendations could be obtained in order to improve pain relief and quality of life.

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Role of Oxycodone Hydrochloride in Treating Radiotherapy-Related Pain

Pain Research and Management ◽

10.1155/2020/7565962 ◽

2020 ◽

Vol 2020 ◽

pp. 1-8

Author(s):

Yinxia Wang ◽

Ligang Xing

Keyword(s):

Quality Of Life ◽

Side Effects ◽

Cancer Pain ◽

Cancer Patients ◽

Pain Control ◽

Analgesic Drugs ◽

Oxycodone Hydrochloride ◽

Radiation Esophagitis

Radiotherapy is commonly used to treat cancer patients. Besides the curable effect, radiotherapy also could relieve the pain of cancer patients. However, cancer pain is gradually alleviated about two weeks after radiotherapy. In addition, cancer patients who receive radiotherapy may also suffer from pain flare or radiotherapy-induced side effects such as radiation esophagitis, enteritis, and mucositis. Pain control is reported to be inadequate during the whole course of radiotherapy (before, during, and after radiotherapy), and quality of life is seriously affected. Hence, radiotherapy is suggested to be combined with analgesic drugs in clinical guidelines. Previous studies have shown that radiotherapy combined with oxycodone hydrochloride can effectively alleviate cancer pain. In this review, we firstly presented the necessity of analgesia during the whole course of radiotherapy. We also sketched the role of oxycodone hydrochloride in radiotherapy of bone metastases and radiotherapy-induced oral mucositis. Finally, we concluded that oxycodone hydrochloride shows good efficacy and tolerance and could be used for pain management before, during, and after radiotherapy.

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A Systematic Review of Randomized Trials on the Effectiveness of Opioids for Cancer Pain

January 2018 - Pain Physician ◽

10.36076/ppj.2012/15/es39 ◽

2012 ◽

Vol 3S;15 (3S;7) ◽

pp. ES39-ES58 ◽

Cited By ~ 1

Author(s):

Lakshmi Koyyalagunta

Keyword(s):

United States ◽

Systematic Review ◽

Side Effects ◽

Pain Relief ◽

Cancer Pain ◽

Outcome Measures ◽

Randomized Trials ◽

Transdermal Fentanyl

Background: In all recommended guidelines put forth for the treatment of cancer pain, opioids continue to be an important part of a physician’s armamentarium. Though opioids are used regularly for cancer pain, there is a paucity of literature proving efficacy for long-term use. Cancer is no longer considered a “terminal disease”; 50% to 65% of patients survive for at least 2 years, and there are about 12 million cancer survivors in the United States. There is a concern about side effects, tolerance, abuse and addiction with long-term opioid use and a need to evaluate the effectiveness of opioids for cancer pain. Objective: The objective of this systematic review was to look at the effectiveness of opioids for cancer pain. Study Design: A systematic review of randomized trials of opioids for cancer pain. Methods: A comprehensive review of the current literature for randomized controlled trials (RCTs) of opioids for cancer pain was done. The literature search was done using PubMed, EMBASE, Cochrane library, clinical trials, national clearing house, Web of Science, previous narrative systematic reviews, and cross references. The studies were assessed using the modified Cochrane and Jadad criteria. Analysis of evidence was done utilizing the modified quality of evidence developed by United States Preventive Services Task Force (USPSTF). Outcome Measures: Pain relief was the primary outcome measure. Secondary outcome measures are quality of life (QoL) and side effects including tolerance and addiction. Results: The level of evidence for pain relief based on the USPSTF criteria was fair for transdermal fentanyl and poor for morphine, tramadol, oxycodone, methadone, and codeine. Limitations: Randomized trials in a cancer setting are difficult to perform and justify. There is a paucity of long-term trials and this review included a follow-up period of only 4 weeks. Conclusion: This systematic review of RCTs of opioids for cancer pain showed fair evidence for the efficacy of transdermal fentanyl and poor evidence for morphine, tramadol, oxycodone, methadone, and codeine. Key words: Opioids, pain relief, cancer pain, morphine, hydromorphone, methadone, fentanyl, oxymorphone, hydrocodone, oxycodone, buprenorphine.

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Pain management

Oxford Textbook of Medicine ◽

10.1093/med/9780198746690.003.0064 ◽

2020 ◽

pp. 629-633

Author(s):

Marie Fallon

Keyword(s):

Quality Of Life ◽

Pain Management ◽

Pain Relief ◽

Adverse Effects ◽

Cancer Pain ◽

Daily Functioning ◽

Opioid Analgesia ◽

Patients With Cancer ◽

Good Pain Relief

Pain occurs in more than 50% of patients with advanced disease, interferes with daily functioning and quality of life, and is very often undertreated. Patients can find it difficult to articulate the character of their pains, but it is important to determine whether it is somatic, neuropathic, or visceral since this has important implications for management. For most patients with cancer pain, a three-step approach combining simple or opioid analgesia (depending on severity) along with an adjuvant analgesic (depending on cause) will result in good pain relief, but the challenge is to achieve good pain relief without unacceptable adverse effects.

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Parenteral Hydration in Patients with Advanced Cancer (DRAFT)

10.1093/med/9780190658618.003.0020 ◽

2018 ◽

Author(s):

Carlos Eduardo Paiva ◽

Bianca Sakamoto Ribeiro Paiva

Keyword(s):

Quality Of Life ◽

Advanced Cancer ◽

Clinical Case ◽

Fluid Intake ◽

Hospice Care ◽

Important Study ◽

The Common ◽

To Receive

There has been much debate about the role of parenteral hydration in the last weeks and days of life. In this important study, 129 patients with advanced cancer receiving hospice care with mild to moderate dehydration who were no longer able to maintain adequate fluid intake were randomized to receive parenteral hydration of either 1 L or 100 ml of normal saline per day subcutaneously. Parenteral hydration did not significantly improve the symptoms related to dehydration, the occurrence of delirium, fatigue, quality of life, and overall survival. At the end of the chapter, a clinical case leads readers to consider the common practice of parenteral hydration.

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