Analgesic Effectiveness of Systemic Lidocaine Administration for Abdominal Cancer Pain Caused by Peritoneal Carcinomatosis: A Case Series of 10 Patients

Abstract

Dear Editor:

Peritoneal carcinomatisis (PC) is defined as one of the tumor-related visceral pain syndromes.¹ Abdominal pain caused by PC is often refractory to opioids, because it complexly involves nociceptive pain and neuropathic pain.^2,3 Our recent animal experiments demonstrated that down regulation of μ-opioid receptors occurs in PC model mice.³

Lidocaine is used as adjuvant analgesics for opioid refractory cancer pain.⁴ In Japan, abdominal pain caused by PC has been treated with continuous intravenous (CIV) lidocaine administration (CIV-lidocaine) with frequent effectiveness; however, the analgesic effectiveness has not been reported.

We conducted a retrospective chart review to report the effective cases of CIV-lidocaine for abdominal pain caused by PC. We selected patients who were treated effectively with CIV-lidocaine for abdominal pain caused by PC, in whom opioids were ineffective despite dose titration, from August 2007 to March 2014. All were diagnosed with PC by computed tomography scanning and the pathological diagnosis of intraperitoneal tissues or ascites. They could evaluate the pain intensity as numerical pain rating scale (0–10). Primary parameters reflecting the analgesic effectiveness of CIV-lidocaine were daily changes in average pain intensity during the past 24 hours as pain intensity difference (PID) between start (baseline) and follow-up after 24, 48, and 72 hours. Secondary parameters were daily changes in frequency of opioid rescue doses. The safety of lidocaine was observed for 72 hours after administration. Patients' previous analgesics and adjuvant analgesics were unchanged throughout the period.

Ten patients effectively evaluated CIV-lidocaine for abdominal pain caused by PC (Table 1). The median reductions in daily pain intensity as PID between baseline and follow-up after 24, 48, and 72 hours were 53.6% (interquartile range [IQR] 42.1–72.3), 58.6% (IQR 48.2–76.3), and 75.7% (IQR 57.5–89.3), respectively. The median reductions in daily frequency of rescue doses between baseline and after 24, 48, and 72 hours were 18.9% (IQR 71.4–52), 37.8% (IQR 5.0–78.6), and 80.5% (IQR 19.3–89.3), respectively. The median starting dose of CIV-lidocaine was 480 mg/day (IQR 250–500), reaching maximum of 500 mg/day (IQR 495–728). In our cases, increasing dose of CIV-lidocaine further improved the abdominal pain intensity, but not other cancer pain. Six of them received CIV-fentanyl (median dosage 0.57 mg/day, IQR 0.23–1.41), three received CIV-morphine (72 mg/day, 120 mg/day, and 1500 mg/day), and one received controlled-release oxycodone (35 mg/day) at start of CIV-lidocaine. The common clinical findings and objective symptoms were abdominal distension (90%), rebound tenderness (80%), and tenderness (80%). There were no serious adverse events associated with CIV-lidocaine.

Table 1.

Analgesic Effectiveness of Lidocaine for Opioid Refractory Abdominal Pain Caused by Peritoneal Carcinomatosis

No.	Gender/age	Diagnosis	NRS ^1 after 0/24/48/72 (hours)*	Frequency of rescue dose before 24–0/after 0–24/24–48/48–72 (hours)	Dosage of lidocaine initial/maximum (mg/day)	Opioids (mg/day)	Rebound tenderness	Tenderness	Abdominal distension	Spontaneous pain	Abdominal wall	Ascites ^*2
1	F/37	Uterine cancer	5/1/2/0	17/9/15/11	500/750	MI (1500)	+	+	+	−	Soft	Mild
2	F/45	Liposarcoma	7/2/4/2	13/7/15/8	480/720	MI (120)	+	+	+	+	Hard	Moderate
3	M/32	Synovial sarcoma	5/2/2/2	3/1/0/0	480/480	CO (35)	−	−	+	+	Hard	Large
4	F/55	Uterine cancer	7/3/5/2	1/3/2/2	480/960	FI (0.3)	+	+	+	+	Soft	Moderate
5	F/64	Pancrease cancer	4/2/2/2	7/6/6/9	500/500	FI (0.96)	−	−	−	−	Soft	Little
6	F/58	Uterine cancer	5/3/1/1	7/12/2/1	100/500	FI (0.2)	+	+	+	−	Soft	Large
7	F/53	Gastric cancer	8/2/2/0	14/14/10/3	500/500	FI (0.84)	+	+	+	+	Hard	Little
8	F/47	Ovarian cancer	7/4/3/1	17/13/9/3	300/300	FI (2.76)	+	+	+	+	Hard	Moderate
9	F/58	Ovarian cancer	5/3/1/1	7/12/2/1	100/500	FI (0.24)	+	+	−	−	Soft	Large
10	F/51	Gastric cancer	4/2/2/2	7/0/0/0	500/500	MI (72)	+	+	+	+	Hard	Large

CO, controlled-release oxycodone; FI, continuous fentanyl injection; MI, continuous morphine injection; NRS, numerical pain rating scale (0–10, where 0 corresponded to no pain and 10 to the worst possible pain).

NRS^*1 = average pain intensity during the past 24 hours as NRS.

Ascites^*2 = Ascites was graded as little (<Grade 1), mild (Grade 1), moderate (Grade 2) or severe (Grade 3) based on the definition indicated by the International Ascites Club in 2003.

We first showed the analgesic effectiveness of CIV-lidocaine for abdominal pain caused by PC. Nevertheless, this study had some limitations due to its small number subjects and single-center retrospective study. The prospective and large multicenter clinical study is now planned to confirm the effectiveness of CIV-lidocaine for abdominal pain caused by PC.

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