1. Palliative care For cancer patients Team approach

2. Sympathy is not enough

3. What can we do ?

5. Better quality of life

6. Cancerpainmanagement Dr. Ahmed Helmy Abouel Soud Board member of WSPC Professor of Pain Relief, N.C.I., Cairo University, Egypt

7. Cancerpain • 70 % of advanced cases • Any site & any type

8. Tools • Drugs • Interventions

9. Pharmacotherapy • WHO ladder system • By the clock • Oral or transdermal rout • Full dose

10. WHO ladder system • Non opioid ± adjuvants • Weak opioids + I • Strong opioids + I

11. Oral weak opioids e.g. tramundine, D.H.C. Oral strong opioids e.g. MST, oxycontin and MXL Transdermal e.g. Fentanyl patch (Durogesic) Sustainedreleaseopioids

12. Simpler, thinner Better adhesion Fentanyl in dissolved state with no ethanol as permeation enhancer Can be divided Guarantee stable blood fentanyl level for 72 h Newer Fentanyl (Durogesic) patch

13. Side effects

14. Delivery of opioids to the C.N.S. Destruction of pain pathway Pain interventionsminimally invasive procedures

15. Delivery of opioids to the C.N.S. • Frequent delivery by special device • Generalized pain, initial good response to the systemic drug with appearance of tolerance or side effects, adequate test response • Better response with lower dose and lesser side effects

16. Pain pathway destruction • Advanced cancer • Localized severe pain • Accessible target

17. Ideal procedure • Life long • High success rate with selective destruction • Complete or satisfactory pain relief • Percutaneous by R.F. or neurolytics • Under local anesthesia • No or minimal morbidity

18. Commontargets • Celiac plexus • Superior hypogastric plexus • Ganglion impar • Posterior root • Spinothalamic tract • Trigeminal tract & nucleus

19. Neurolytic procedures • Celiac plexus • Superior hypogastric plexus • Ganglion impar • Posterior root

20. Celiac plexus destruction • Upper abdominal visceral pain • Pancreas, hepatobiliary, stomach, intestine • 85% success

21. CeliacPlexus

22. Superior hypogastric plexus destruction • Pelvic visceral pain • Bladder, prostate, cervix, uterus, ovary, colon& rectum • 75% success

23. Ganglion impar • Junction of the two paravertebral sympathetic chains • Sacroccygeal junction • SMP at the perineal region • Ca rectum, anal canal, vagina& vulva • 50-60% success

24. Posterior (sensory) root • Localized somatic • Rib metastases, ca rectum & anal canal • 70% success • Sensory loss

25. Cordotomy Tractotomy-nucleotomy Spinothalamic tract Trigeminal tract & nucleus Percutaneous RF procedures

26. Crossed fibers Anterolateral quadrant Pain & temperature Somatotopic organization Important relations Spinothalamic tract

27. Cordotomy • Unilateral cancer pain below the clavicle • Lung, pleura, pelvic bones & muscles, upper & lower limb • 95% success • Loss of pinprick & temp

28. Descending trigeminal tract & subnucleus caudalis • Posterolateral part • Joined by VII, IX and X • Somatotopic organization • Important relations • Pain & temperature

29. Trigeminal Tractotomy-Nucleotomy • Percutaneous • under L.A. & sedation • C-T guided • R.F. • Occiput / C1 level • 75 % success

30. Can we offer this ?