The effect of ketamine as adjuvant to opioid for intractable cancer pain / 대한내과학회지

BACKGROUND: There has been growing evidence of the importance of the N-methyl-D- aspartate (NMDA) receptor in intractable pain. There is good evidence from experimental animal models and clinical trials that ketamine as a NMDA receptor antagonist relieves neuropathic pain. We evaluated whether ketamine in low doses as an adjuvant to opioid treatment improves analgesia with tolerable adverse effects. METHODS: 58 patients with intractable cancer pain received ketamine for 3 days. Each pain type was classified as a somatic, visceral, or neuropathic pain. We assessed pain at 6 hourly intervals with vital signs using a numeric rating scale. Data on opioid doses, ketamine dose, and adverse effects were recorded daily on an assessment chart. To be designated as a responder, a patient had to show a 50% or greater reduction in the mean pain scale. RESULTS: The overall response rate was 34.5%. The results according to the type of pain mechanism showed that 47% (15/32) patients with neuropathic and 25% (5/20) patients with somatic pain responded. In 24 cases (41.4%), the requirement for an opioid dose was reduced after infusion of ketamine. The most common adverse effects were nausea and vomiting. Eleven patients complained of drowsiness or transient hallucination. However, most adverse effects were mild to moderate and were easily relieved by treatment. CONCLUSIONS: This study demonstrates that the infusion of ketamine in low doses may have an effect on intractable cancer pain and in reducing opioid requirements, especially neuropathic pain with acceptable toxicities. Therefore, ketamine may be useful as an adjuvant to opioid treatment in cancer patients who are receiving palliative care.

Intrathecal Catheter and Subcutaneous Access Port Implantation in Pain Management for Terminal Cancer Patient: A case report / 대한통증학회지

It is important to treat cancer-related pain in cancer patients to ensure the life quality of the patient, as well as to improve their life span. It has been estimated that at least 5% of cancer patients have pain refractory to medical treatment. Therefore, the need for epidural or intrathecal analgesia with opioids and local anesthetics is indicated if systemic treatment has failed. Intrathecal catheter placement and implantation of the injection port for administration of opioids and local anesthetics may improve pain relief in patients who are unresponsive to epidural routes. Although intrathecal implantation has several complications, similar infection rates have been reported between intrathecal and epidural administration. In addition, intrathecal administration showed better outcomes, including improved pain control, lowered daily doses, and an improvement in the level of drowsiness experienced when compared to epidural administration. We report here a case in which a terminal cancer patient was treated using an intrathecal catheter and subcutaneous port. The patient had cancer-related pain that could not be controlled by epidural opioid administration. Based on the results presented here, we suggest that intrathecal implantation is a feasible long term pain management method for intractable cancer pain patients.

Pituitary Irradiation by Gamma Knife in Intractable Cancer Pain

OBJECTIVE: Cancer pain has been treated by gamma knife radiosurgery(GKS), targeted to the pituitary gland-stalk, as an alternative new pain control method. The purpose of this study is to prove the efficacy and the safety of this treatment. METHODS: Seven patients with intractable cancer pain underwent pituitary gland-stalk irradiation by gamma knife. Selections for patient inclusion in this treatment protocol were no other effective pain treatment options, general condition rated as greater than 40 on Karnofsky Performance Scale, and pain relief by morphine though not satisfactory. The target was the junction between the pituitary stalk and the neurohypophysis. The maximum dose was 150~160Gy with one isocenter in 8mm collimator or two isocenters in 4mm collimator keeping the radiation dose to the optic nerve less than 8Gy. RESULTS: In all seven cases, the significant pain reduction was obtained during immediate post-GKS period without serious complications except one patient who developed transient hypopituitarism and diabetes insipidus. Pain relief was observed within several days, and this effect was prolonged for a quite long time. At a follow up of 1.5 to 13 months, pain recurred in two patients and no hormonal and visual dysfunctions were observed. CONCLUSION: Despite insufficient experience, the efficacy and the safety of GKS for intractable cancer pain were demonstrated in seven patients. This treatment has the potential to ameliorate cancer pain, and GKS will play a more important role in the treatment of intractable pain.

Clinical application of an improved ruler for fixing stereotactic head frame / 中国微创外科杂志

Objective To study a simple, measurable and objective method for fixing stereotactic head frame. Methods A self-made stereotactic head frame ruler was used in the localization in operations of 29 cases of Parkinson's disease and 1 case of intractable cancer pain. Results Of the 30 cases,significant effects were obtained in 29 coses(96.7%) and curative effects in 1 case (3.3%). Conclusions The improved ruler can be fully applicable to the ASA-602S model stereotactic frame, being a simple, measurable and objective method for fixing stereotactic head frame and applying CT scanning orientation.

Clinical Analysis on Open Thoracic Cordotomy of the Cancer Pain

Patients with pain syndromes resulting from recurrent or metastatic cancer should be evaluated carefully to determine the cause of their pain and the need for appropriate antitumor treatment. The most effective ablative pain control procedure at the current time is cordotomy, which is indicated in patients with unilateral pain. The authors results of 12 antero-lateral thoracic cordotomies performed for intractable cancer pain between 1996-1998. The follow-up of these patients was continued for at least 12 months or until death to determine the late success of this procedure. Excellent surgical results were obtained in 100% after one week and in 50% in 6 months after operation. The operation was considered to be successful for patients with malignant disease of short life expectancy.