Interventional Techniques Supportive Care in Pediatric Oncology irantextbook.ir 93df

Gabapentin and opioid agents have been used to treat vincristine-related neuropathic pain alone or in combination. Gabapentin, in doses ranging from 10 mgkgday up to 50–70 mgkgday, was well tolerated and reduced pain scores amongst children undergoing ALL treatment Anghelescu et al. 2011 . Studies from adult patients with peripheral neuropathy from other causes have shown that coadministration of gabapentin with opioids resulted in signifi cantly better pain control than placebo or either agent alone Gilron et al. 2005 . This synergistic effect was also observed in rat models Matthews and Dickenson 2002 . Prior to gabapentin, TCAs were considered fi rst-line therapy for neuropathic pain and can be considered see Sect. 9.5.3 Sindrup and Jensen 1999 . Mouse models implicating 5-HT2A recep- tor involvement in neuropathic pain have led to interest in the use of SNRIs though clinical evi- dence in humans is lacking Marchand et al. 2003 ; Thibault et al. 2008 . Case reports have discussed use of pyridoxine and pyridostigmine with some effect but larger case series or trials have not been performed Akbayram et al. 2010 . Other chemo- therapeutic agents linked to neuropathic pain syn- dromes include other vinca alkaloids vinblastine, vinorelbine, platinum agents cisplatin, oxalipla- tin, taxanes paclitaxel, docetaxel and newer agents like bortezomib Han and Smith 2013 .

9.8.2 Osteonecrosis

Osteonecrosis ON is a painful and potentially crippling condition typifi ed by ischemic and necrotic changes in bone. In children, ON is com- monly associated with corticosteroid exposure in ALL and lymphoma but can occur independent of steroid therapy in cancers involving bone or bone marrow Vora 2011 . Additional risk factors for ON include age 10 years, obesity, Caucasian race, treatment intensity and asparaginase use Mattano et al. 2000 ; Niinimaki et al. 2007 ; Kawedia et al. 2011 . While many children treated for ALL have evidence of ON on mag- netic resonance imaging MRI, symptomatic ON incidence is 20 Mattano et al. 2000 ; Kawedia et al. 2011 ; Hyakuna et al. 2014 . Pain from ON ranges from mild intermittent pain to chronic debilitating pain. Analgesic treat- ment for ON should follow the general guide- lines of the WHO pain ladder see Sect. 9.4.1 starting with NSAIDs, if appropriate. COX2 inhibitors such as celecoxib may be preferable in patients for whom antiplatelet effects are a con- cern. Intermittent short-acting opioids may be suffi cient for patients who cannot tolerate NSAID therapy. Patients with persistent pain requiring multiple doses of opioids per day benefi t from long-acting opioids. In patients with chronic pain, methadone is an attractive option given its resistant nature to opioid tolerance. Patients who develop chronic pain from ON may best be served by a chronic pain management specialist. Bisphosphonate therapy has been recently investigated as a method for reducing pain in patients with ON. An Australian study risk strati- fi ed a small population of children with ON and found reduction in pain amongst “severe risk” patients who received monthly IV pamidronate versus “moderate risk” patients receiving oral bisphosphonates and “mild risk” patients receiv- ing calciumvitamin D supplementation Kotecha et al. 2010 . A Canadian study similarly found that 1417 77 patients with symptomatic ON noted pain relief with a 3-day course of IV pami- dronate given every 4 months Leblicq et al. 2013 . A study investigating zoledronic acid in children has demonstrated similar results Padhye et al. 2013 . Referral to an orthopedic surgeon experienced in ON management can be benefi cial, especially for patients with signifi cant debilitating symptoms. Surgical options which can improve functionality and reduce pain include core decom- pression and joint replacement. Other suggested supportive care measures for ON include physical therapy, weight loss, and treatment of vitamin D defi ciency, if present Vora 2011 .

9.8.3 Post-lumbar Puncture

Headache Lumbar puncture LP is a common diagnostic and therapeutic procedure in pediatric oncology. Although relatively uneventful, the most common