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Design and Participants: This trial at eight hospitals (Israel, Poland, Canada, USA, Portugal) assessed the effect of a single fraction of 25 Gy of external-beam photons to the celiac plexus on retroperitoneal pain. Patients (aged ≥18yrs) had retroperitoneal pain syndrome, uncontrolled despite analgesia, with a pain score of mean 5 to 10 on the Brief Pain Inventory (Short Form) (BPI-SF), an Eastern Cooperative Oncology Group performance status score of 0 to 2, and pancreatic cancer or other tumors involving the celiac axis. The primary endpoint was BPI-SF mean score reduction of 2 or more points, from baseline to 3 weeks posttreatment. Analyses used linear mixed modeling and t tests.
Results: Patients (N=90; followed until death) were aged median 66 years old (IQR=58-72); 56% female; and 94% White, 3% Asian, and 1% Hispanic. Baseline mean BPI-SF score was median 6 (IQR=5-7); 53% (95% CI=42-64) had a score reduction of 2 points or more at 3 weeks. The most common grade 3-4 adverse events, irrespective of attribution, were abdominal pain (28%) and fatigue (18%). Eleven serious adverse events of grade 3 or higher were recorded: two grade 3 were probably attributed to treatment by the local investigators (abdominal pain [n=1] and nausea [n=1]), and nine were possibly attributed to treatment (seven grade 3: blood bilirubin increase [n=1], duodenal hemorrhage [n=2], abdominal pain [n=2], and progressive disease [n=2]; and two grade 5: gastrointestinal bleed from suspected varices 24 days posttreatment [n=1] and progressive disease [advanced pancreatic cancer] 89 days posttreatment [n=1]).
Commentary: This single arm, phase 2 trial of stereotactic celiac plexus radiosurgery (a minimally invasive alternative to celiac plexus block or neurolysis, which both have variable reported efficacy) showed decreased pain scores at 3 weeks in 53% of patients and no increase in opioid doses in 40%.3 Of the responding patients, 40% had a modest decrease in opioid dose (5mg IV morphine) at 6 weeks, lagging 3 weeks behind reduction in pain scores. It remains unclear if reduction in pain scores were directly attributable to the intervention; the destruction of adjacent infiltrating tumor cells; the effect of weekly palliative care nursing phone assessments; or other antineoplastic treatments, which were only prohibited ±6 days from the intervention. Also, limited availability of high-technology radiotherapy could restrict broad access to this intervention.
Bottom Line: Celiac plexus radiosurgery showed reduction in retroperitoneal pain and opioid use in patients with advanced pancreatic cancer and warrants additional randomized controlled trials.
Reviewer: Sonal Admane, MD MPH, University of Texas MD Anderson Cancer Center, Houston, TX
References:
1. Gropper MA, Eriksson LI, Fleisher LA, Wiener-Kronish JP, Cohen NH, Leslie K, eds. Miller’s Anesthesia, 2-Volume Set. 9th ed. Elsevier; 2019. Philadelphia, PA: Elsevier Health Sciences 2019: 403-419.
2. Standring S, ed. Gray’s Anatomy: The Anatomical Basis of Clinical Practice. 42nd ed. Elsevier; 2020: 1107-1121.
3. Wong GY, Schroeder DR, Carns PE, et al. Effect of neurolytic celiac plexus block on pain relief, quality of life, and survival in patients with unresectable pancreatic cancer: a randomized controlled trial. JAMA. 2004;291(9):1092-1099. doi:10.1001/jama.291.9.1092.
Source: Lawrence YR, Miszczyk M, Dawson LA, et al. Celiac plexus radiosurgery for pain management in advanced cancer: a multicentre, single-arm, phase 2 trial. Lancet Oncol. 2024;25(8):1070-1079. doi:10.1016/S1470-2045(24)00223-7.
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