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      Computed Tomography-Guided Coeliac Plexus Neurolysis in Palliative in-Patients with Intra-Abdominal Malignancy: Retrospective Evaluation of Neurolytic Solution Spread as a Predictive Factor

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          Abstract

          Introduction

          Computed tomography (CT)-guided coeliac plexus neurolysis (CPN) is considered effective at controlling pain in patients with intra-abdominal malignancies. The primary objective was to correlate pain outcomes with the spread of neurolytic solution in the coeliac area and to evaluate the predictive value for the spread of injectate for pain outcomes and side effects.

          Methods

          Blinded CT scans were reviewed. The coeliac area was divided into nine quadrants. Assessors evaluated quadrants according to contrast spread, needle tip position, and the contact between the injectate and other organs and plexuses. Efficacy of CPN and complications were estimated.

          Results

          In 54.9% there was complete spread of the neurolytic in the coeliac area with no correlation between pain relief and spread of injectate. In 85% the neurolytic had contact with viscera with no correlation with pain relief or complications. There was no correlation between needle tip position and spread of the neurolytic and contact of the neurolytic with viscera. In 71.6% the injectate was found to have spread into “other” plexuses. In 13.3% hampered spread of the injectate was observed. There was no correlation between patterns of injectate spread and pain relief, pain relief and spread of injectate in any particular quadrants, and expected and documented post-procedural pain scores.

          Conclusions

          Based on the spread of contrast medium clinicians can neither correctly anticipate the pain relief or post-procedural NRS, nor the duration of pain relief and complications. It is not essential to have the perfect sickle-shaped spread of the injectate for adequate pain control.

          Plain language summary

          CT-guided coeliac plexus neurolysis is considered effective at controlling pain in patients with intra-abdominal malignancies. Based on the spread of contrast medium clinicians can neither correctly anticipate the pain relief or post-procedural NRS, nor the duration of pain relief and complications. It is not essential to have the perfect sickle-shaped spread of the injectate for adequate pain control.

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          Most cited references27

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          Neuroplastic changes occur early in the development of pancreatic ductal adenocarcinoma.

          Rachelle Stopczynski, Daniel P. Normolle, Douglas J. Hartman … (2014)
          Perineural tumor invasion of intrapancreatic nerves, neurogenic inflammation, and tumor metastases along extrapancreatic nerves are key features of pancreatic malignancies. Animal studies show that chronic pancreatic inflammation produces hypertrophy and hypersensitivity of pancreatic afferents and that sensory fibers may themselves drive inflammation via neurogenic mechanisms. Although genetic mutations are required for cancer development, inflammation has been shown to be a precipitating event that can accelerate the transition of precancerous lesions to cancer. These observations led us to hypothesize that inflammation that accompanies early phases of pancreatic ductal adenocarcinoma (PDAC) would produce pathologic changes in pancreatic neurons and innervation. Using a lineage-labeled genetically engineered mouse model of PDAC, we found that pancreatic neurotrophic factor mRNA expression and sensory innervation increased dramatically when only pancreatic intraepithelial neoplasia were apparent. These changes correlated with pain-related decreases in exploratory behavior and increased expression of nociceptive genes in sensory ganglia. At later stages, cells of pancreatic origin could be found in the celiac and sensory ganglia along with metastases to the spinal cord. These results demonstrate that the nervous system participates in all stages of PDAC, including those that precede the appearance of cancer.
          Article 0 comments Cited 56 times – based on 0 reviews     Review now
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            Prognostic factors and sites of metastasis in unresectable locally advanced pancreatic cancer

            Renata D'alpino Peixoto, Caroline Speers, Colleen E McGahan … (2015)
            Due to differences in natural history and therapy, clinical trials of patients with advanced pancreatic cancer have recently been subdivided into unresectable locally advanced pancreatic cancer (LAPC) and metastatic disease. We aimed to evaluate prognostic factors in LAPC patients who were treated with first-line chemotherapy and describe patterns of disease progression. Patients with LAPC who initiated first-line palliative chemotherapy, 2001–2011 at the BC Cancer Agency were included. A retrospective chart review was conducted to identify clinicopathologic variables, treatment, and subsequent sites of metastasis. Kaplan–Meier and Cox-regression survival analyses were performed. A total of 244 patients were included in this study. For the majority of patients (94.3%), first-line therapy was single-agent gemcitabine. About 144 (59%) patients developed distant metastatic disease and the most frequent metastatic sites included peritoneum/omentum (42.3%), liver (41%), lungs (13.9%), and distant lymph nodes (9%). Median overall survival (OS) for the entire cohort was 11.7 months (95% CI, 10.6–12.8). Development of distant metastases was associated with significantly inferior survival (HR 3.56, 95% CI 2.57–4.93), as was ECOG 2/3 versus 0/1 (HR 1.69, 95% CI 1.28–2.23), CA 19.9 > 1000 versus ≤1000 (HR 1.59, 95% CI 1.19–2.14) and female gender, (HR 1.57, 95% CI 1.19–2.08). In this population-based study, 41% of LAPC patients treated with first-line chemotherapy died without evidence of distant metastases. Prognostic factors for LAPC were baseline performance status, elevated CA 19.9, gender, and development of distant metastasis. Results highlight the heterogeneity of LAPC and the importance of locoregional tumor control.
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              CT-guided celiac plexus neurolysis: a review of anatomy, indications, technique, and tips for successful treatment.

              Avinash K Kambadakone, Ashraf Thabet, Debra Gervais … (2011)
              The celiac plexus is the largest visceral plexus and is located deep in the retroperitoneum, over the anterolateral surface of the aorta and around the origin of the celiac trunk. It serves as a relay center for nociceptive impulses that originate from the upper abdominal viscera, from the stomach to the proximal transverse colon. Celiac plexus neurolysis, with agents such as ethanol, is an effective means of diminishing pain that arises from these structures. Percutaneous imaging-guided celiac plexus neurolysis has been established as an invaluable therapeutic option in the management of intractable abdominal pain in patients with upper abdominal malignancy. The use of multidetector computed tomography (CT) for imaging guidance has superseded other modalities and allows direct visualization of the spread of the neurolytic agent in the antecrural space. Accurate depiction of the retroperitoneal anatomy and the position of the needle tip helps avoid crucial anatomic structures such as the pancreas, aorta, celiac artery, and superior mesenteric artery. Proper patient education, meticulous preprocedure planning, use of optimal multidetector CT techniques, adjunctive CT maneuvers, and postprocedure care are integral to successful celiac plexus neurolysis. Celiac plexus neurolysis does not completely abolish pain; rather, it diminishes pain, helping to reduce opioid requirements and their related side effects and improving survival in patients with upper abdominal malignancy.
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                Author and article information

                Contributors
                Markus Köstenberger:
                ORCID: http://orcid.org/0000-0002-7205-6818
                markus.koestenberger@kabeg.at
                Journal
                Journal ID (nlm-ta): Pain Ther
                Journal ID (iso-abbrev): Pain Ther
                Title: Pain and Therapy
                Publisher: Springer Healthcare (Cheshire )
                ISSN (Print): 2193-8237
                ISSN (Electronic): 2193-651X
                Publication date (Electronic): 11 August 2022
                Publication date PMC-release: 11 August 2022
                Publication date (Print): December 2022
                Volume: 11
                Issue: 4
                Pages: 1229-1243
                Affiliations
                [1 ]GRID grid.415431.6, ISNI 0000 0000 9124 9231, Centre for Interdisciplinary Pain Therapy, Oncology and Palliative Care, , Klinikum Klagenfurt am Wörthersee, ; Feschnigstrasse 11, 9020 Klagenfurt am Wörthersee, Austria
                [2 ]GRID grid.11598.34, ISNI 0000 0000 8988 2476, Medical University of Graz, ; Graz, Austria
                [3 ]GRID grid.7520.0, ISNI 0000 0001 2196 3349, Department of Statistics, , Alpen-Adria University Klagenfurt, ; Klagenfurt am Wörthersee, Austria
                [4 ]GRID grid.415431.6, ISNI 0000 0000 9124 9231, Department of Neurosurgery, , Klinikum Klagenfurt am Wörthersee, ; Klagenfurt am Wörthersee, Austria
                [5 ]GRID grid.415431.6, ISNI 0000 0000 9124 9231, Institute of Interventional and Diagnostic Radiology, , Klinikum Klagenfurt am Wörthersee, ; Klagenfurt am Wörthersee, Austria
                [6 ]GRID grid.263618.8, ISNI 0000 0004 0367 8888, Sigmund Freud University Vienna, ; Vienna, Austria
                [7 ]GRID grid.412581.b, ISNI 0000 0000 9024 6397, Institute for Anatomy and Clinical Morphology, , Witten/Herdecke University, ; Witten, Germany
                Author information
                http://orcid.org/0000-0002-7205-6818
                Article
                Publisher ID: 423
                DOI: 10.1007/s40122-022-00423-8
                PMC ID: 9633888
                PubMed ID: 35953656
                SO-VID: a75f9f80-7f1d-4da0-8b19-edb175020166
                Copyright © © The Author(s) 2022
                License:

                Open AccessThis article is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, which permits any non-commercial use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc/4.0/.

                History
                Date received : 5 July 2022
                Date accepted : 27 July 2022
                Categories
                Subject: Original Research
                Custom metadata
                issue-copyright-statement © The Author(s) 2022

                Keywords: predictive factors,coeliac plexus neurolysis,interventional pain therapy,invasive pain management,neurolytic coeliac plexus block
                Data availability:
                Keywords: predictive factors, coeliac plexus neurolysis, interventional pain therapy, invasive pain management, neurolytic coeliac plexus block

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