Hello, my name is Susan Urba. I'm a medical oncologist and I specialize in the treatment of esophageal cancer. I'm also a palliative care physician specializing in pain and symptom management for patients. I've prepared six modules representing the oncologist's perspective on the treatment of patients with esophageal cancer. This module is part one of two modules on pain management and this is for pain management for patients with thoracic malignancies. So we will also mention some patients with lung cancer in addition to esophageal cancer. So, the objectives are to understand some of the causes of cancer pain. This will include tumor pain, esophageal spasm, peritoneal carcinomatosis, bone metastases, neuropathic pain. Which is primarily from celiac node involvement in esophageal cancer, and a Pancoast tumor in lung cancer. To some extent in this module, I'll talk about treatment, but the next module will emphasize even more some of the medical treatments. So we really want to understand treatment related pain also, which can result from mucositis, radiation esophagitis and radiation dermatitis. So, these are the things we will touch upon. So, let's have a pre-lecture question view to think about. What is the best initial treatment for pain from bone metastases? Number 1, opioids and steroids. Number 2, Acetaminophen and NSAID's. Number 3, Gabapentin and nortriptyline or 4, NSAID's plus bisphosphonates. So, let's start by talking about tumor pain. In esophageal cancer, the tumor in the esophagus is going to cause pain on swallowing. Sometimes it's just discomfort, the food won't go down. Sometimes they end up vomiting it up, but sometimes it can really cause a lot of pain in the chest. As you can imagine, if it's trying to go through, the peristalsis is trying to push it through, then they get a bad sense of pressure or burning. For lung cancer, sometimes the lung cancer tumor can cause chest pain that may get worse with deep breathing or with coughing. So, for tumor pain, there is what's called a pain treatment ladder which was organized by the World Health Organization Analgesic Ladder. Starts at the very lowest part, the first step being a non opioid medication, which is usually something like acetaminophen or non-steroidal anti-inflammatory. If the pain increases or needs something more, then we go up the ladder using some of the milder opioids or then some of the more strong opioids. And sometimes, we use a lot of things together to try to get at pain in several different ways. So, let's talk a little about esophageal spasm. This is abnormal muscle contractions, which can be acute usually after eating, but not always and it can be short lived. It might just be like a sudden wave of pain and then it's over and doesn't need treatment, but can really be severe. And I've had numerous patients who didn't know they had esophageal cancer, had severe episodes of chest pain, actually went to the emergency room, had a big cardiac workout to rule out an MI. And then eventually, we discovered to have esophageal cancer that was actually causing severe esophageal spasm. The peristalsis should go right down the esophagus into the stomach, but sometimes it hits up against the tumor and it goes backup and the spasm can be very tough. Some may also have severe reflux, so we can certainly try proton pump inhibitors. For those who have ongoing spasm, sometimes calcium channel blocker medications can be helpful. Sometimes nitrates, we're all used to using those for angina for chest pain, but sometimes using the sublingual nitroglycerine. And kind of vasodilating, getting a little more blood supply there can sometimes help with the esophageal spasm also. So, that was esophageal spasm. Let's move on now to peritoneal carcinomatosis. This is a surgeon's view opening up the abdomen and looking at the various organs. Usually, it should be pink and smooth. Unfortunately, as you can see, there are numerous deposits of white fungating masses. So, those are metastatic deposit from the esophageal cancer. And as you can imagine, when they are sitting there on the organs, they are going to cause numerous problems. Some of the things that can cause is abdominal distension. A lot of times it's sort of a protective mechanism, the abdomen will secrete fluid, which is ascites. So, this will cause the distension and just sort of a diffuse discomfort. If there's a relatively large tumor deposit, it'll just push against one part of the bowel and actually cause bowel obstruction. So if there's ascites, we usually try to do a paracentesis and just drain off the fluid, try to get them to feel a little more comfortable. But if a big deposit is pushing on one aspect of the bowel and they can't move stool through there, then that is a bowel obstruction is an emergency. So usually, we consult surgery to see if there's only one main area of obstruction that they can go in and divert the colon around. That's the best treatment for it. If there's multiple areas of obstruction, so that one surgery of one area wouldn't help. Sometimes, they can't do surgery to relieve it and then we're left with medical management. So, what do we do for medical management? We treat sometimes with opioid medications, because the pain can be severe. The bowel is trying to push against this obstruction, so there are waves of pain. We try to give corticosteroids to reduce inflammation. We try to give anticholinergic medications, such as scopolamine to try to cut down on the peristalsis. We give a drug called octreotide or somatostatin. This may help reduce secretions, so that there aren't that many secretions going through the gut. Sometimes a venting gastrostomy tube is put in, which is a feeding tube into the stomach area. But instead of feeding, we have it venting, getting rid of secretions, so they're not pushing their way through the gut, trying to push past this obstruction. Another possibility that can occur, that will cause pain are bone metastases, both from lung and esophageal cancer. This is a picture of someone's arm, the humerus, which you can see is just that moth eaten area. It should be nice and smooth, but these bones are showing multiple metastases. This would be kind of total deep aching pain, particularly with movement. Radiation is the cornerstone for pain relief and stabilization. These patients have to be careful not to do a lot of weight barring. I had one patient walking his dog with a bad lesion in his humerus and the dog kind of ran and pulled on his arm, and he sustained a fracture. So, that sort of thing can really weaken the bone. So, besides trying to be careful when we give radiation in the meantime, NSAID's is a mainstay, non-steroidal anti-inflammatory drugs. Cuts down on prostaglandins, which is a main pathway of inflammation and can sometimes help this pain. Other ways of getting at the bone pain are bisphosphonates and they inhibit resorption of the bone by osteoclast, and there are several different types of zoledronic acid, pamidronate. These are IV drugs and when we know we have patients with bony metastases, we usually infuse this every three to four weeks to try to help protect the bones. There's also a relatively new drug, which is an antibody that is involved in the osteoclastic activity call denosumab and that can also help strengthen the bones. And these two measures, the bisphosphonates and the monoclonal antibody are given in an effort to reduce skeletal related events. That's all the studies are done, to reduce skeletal related events. So, what are these events? Well, it's pain, pathologic fracture, the need for surgery or even cord compression. So if we know we have someone with bone pain while we're giving them NSAID's and whatnot, we're also trying to prevent further issues by giving radiation or also by giving these treatments listed in this slide here. Other meds that can be given are corticosteroids, another way of getting at prostaglandin synthesis to reduce inflammation. Dexamethasone is probably the most commonly used drug and often these patients will require opioid therapy, because the pan can be quite severe. There's another type of pain called neuropathic pain. And as you can see on the picture here and the words written there, stabbing, pins and needles, electric shock-like, numb, throbbing, shooting, like a lightening bolt. So whenever patients start describing things in an unusual way as opposed to gee, it just hurts, or gee, it just aches, then of course, we think that the nerves and cells might be aggravated. And in patients with esophageal cancer, that may mean that the celiac lymph nodes are involving the celiac nerve plexus. And in lung cancer, if tumor is high up in one aspect of the lung, it can push on the brachial plexus and this is called the Pancoast tumor and this can also cause kind of shooting pain down the arm. So for the celiac adenopathy, that's in the abdomen, caused by the regional adenopathy pushing on the nerves there, the celiac plexus. And they'll complain of abdominal pain radiating to the back, often burning and shooting. In the next module, where I talk more about some of the interventions, I will talk a little more about the neurolytic nerve blocks that are sometimes done. We treat these patients with pain medications, but we also try to do other interventions to just block the conduction down the nerves and here's a picture. You can see right along the aorta, it says, the celiac plexus of nerves. So any tumor or lymph node that might be aggravating those nerves, that's what's going to cause that burning sort of pain in the back of the abdomen. The Pancoast tumor, which is more typical in lung cancer patients. If you look in that patient's right upper lobe, you see sort of a white patchy area. That's where the tumor is pushing against the brachial plexus and the pain is going to radiate down that arm. It invades the parietal pleura, upper ribs, sometimes the vertebral bodies and sometimes it's really severe and unrelenting. So again, asking about this and even if they're just saying it really hurts, maybe they're not not saying it's burning or shooting. Just from the location, we know it's probably involving those nerves, then we sometimes use some of the medications that are specifically used for neuropathic pain and I'll go into that in greater detail. So the neuropathic agents, opioids may be needed and of course, treating the tumor itself. Now, besides the tumor itself, the treatment itself can cause pain. Unfortunately, a lot of the chemo that we give can cause mouth sores or mucositis. This is a particularly bad case, but I've seen this a hundred times if not more. Some of the agents we commonly use, 5-fluorouracil and capecitabine. Sometimes, the taxanes can cause those white patchiness and the red blisters there. Sometimes when we radiate the esophagus, it can cause radiation esophagitis. And if you look down there, it looks red and raw, it's like a bad sunburn I always tell the patients. As you can imagine, when they are trying to eat and food is rubbing against that, that is really painful. So, to try and prevent and treat some of these, we advise that they take salt and soda mouthwashes. They combine salt and baking soda in water. They swish it around and gargle to try, and keep the mouth as clean as possible. Try to keep it from getting a secondary infection. For a mild mucositis, sometimes they'll use like Popsicles or just ice chips to kind of help numb the area. There's also something called magic mouthwash. What is magic mouthwash? Well, the pharmacist usually compounds it and it's usually 3 ingredients and here are several of the categories that some of these ingredients are taken from. Sometimes, an antibiotic is included to help keep bacteria away from these sores. Sometimes a local anesthetic like lidocaine is added to decrease the discomfort. Sometimes an antifungal is added, because they're just set up for getting thrush or very bad fungal infection. Sometimes liquid decadron, oral decadron is used to try to help relieve inflammation and sometimes just a plain old antacid to kind of soothe the area. So in other words, one of our mixtures of magic mouthwash is viscous lidocaine, nystatin, which gets that fungus and diphenhydramine, which is like a local anesthetic. Now, sometimes that's helpful but a lot of times, it's mucositis can be a very tough thing. As you could imagine who'd want to eat, if putting food in their mouth hurts? So, those patients can just lose weight like crazy, so we often will give a fair amount of pain medications. I'll usually give them an opioid. I'll tell them, take it about an hour before eating, so it can digest. You can premedicate, kind of soothe the area before you start sending food past the sores, so that it won't irritate it quite so badly. A lot of the pain medicine like morphine elixir might be better tolerated than pills. Always keeping in mind, if you're prescribing an opiate, you've got to prescribe a laxative, it's the number one side effect. And sometimes if the patients are just in pain all day long rather than just treating them before they eat. We will sometimes give them a long-acting pain medicine so that they're getting covered around the clock, so that they can get some sleep. And then another way that treatment can cause pain is from radiation, sometimes, it can get a bad radiation dermatitis. Now, when you look at the patient's back on the left, it's a mild, it's kind of a pink area, but the gentleman way on the right, that's like a severe burn. And the one in the middle, you can see it's oozing, it's breaking down, it's really like a burn, a second or third degree burn. So depending on the extent of it, we use various ointments. Sometimes a minor irritation, we can use Aquaphor ointment, this is kind of over the counter. But a lot of times, once they really start getting painful or they're starting to breakdown their skin, we usually use something like Silvadene. It's like a white cream, has an antibiotic, has a sulfa antibiotic. They can't take it if they're allergic to sulfa. It can be very soothing and actually in the burn unit when people have very severe burns, this is typically used. So, extrapolating from that, we sometimes use it. Now having said this, a lot of people get through radiation with hardly any problem. But once in a while, someone will have a severe reaction and will really need these treatments as well opioid medications. So let's return now to our question, what's the best initial treatment approach for pain from bone metastases? Opioids and steroids? Acetaminophen and NSAID's? Gabapentin and nortiptyline or NSAID's, and bisphosphonates? And take a minute, put down your answer and the true answer is NSAID's and bisphosphonates. Remember that the NSAID's are really geared towards the bone to prevent prostaglandin production and the bisphosphonates are good at preventing the skeletal related events. Once you get a fracture, then the pain is going to escalate sky high, so these are the things we have to try to prevent. So in summary, the take home points. Pain may result from the cancer itself or from the treatment. Peritoneal carcinomatosis may cause a bowel obstruction, so if that's the case, go straight to surgery if possible. Otherwise, opioids, steroids and octreotide are used. Celiac adenopathy and Pancoast tumors can cause neuropathic pain syndromes, which we will talk about that treatment in our next and last module. And chemo and radiation can lead to mucositis, esophagitis or dermatitis and these do have to be treated with localized measures as well as oral medications. So, I thank you very much for your attention.
