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ORIGINAL ARTICLE
Year : 2019  |  Volume : 15  |  Issue : 4  |  Page : 825-830

Navigated magnetic resonance imaging-guided celiac plexus neurolysis using an open magnetic resonance system for pancreatic cancer patients with upper abdominal pain


1 Department of Interventional Oncology, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
2 Department of Oncology, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China

Date of Web Publication14-Aug-2019

Correspondence Address:
Xuebin Zhang
Department of Interventional Oncology, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai 200127
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.JCRT_38_19

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 > Abstract 


Aims: The study aimed to evaluate the safety and efficacy of navigated magnetic resonance imaging (MRI)-guided celiac plexus neurolysis (CPN) using a 0.4 T open magnetic resonance system.
Materials and Methods: A retrospective analysis was performed on 23 patients with unresectable pancreatic cancer who underwent MRI-guided CPN between January 2013 and October 2017. Clinical outcomes were evaluated by recording the complications, the opioid intake, and questionnaire before the intervention and at the time point of 1 day, 1 month, and 3 months postprocedure using a numerical visual analog scale (VAS).
Results: Navigated MRI guidance allowed the precise placement of needle in the targeted area and the visualization of the injected neurolysis agents for all cases. The VAS scores decreased from 8.8 ± 1.0 to 2.9 ± 0.9, 4.2 ± 1.7, and 4.7 ± 1.8 at 1 day, 1 month, and 3 months postprocedure (P < 0.05). This intervention reduced the dosage of opioid consumption 1 month after the procedure (52.3 ± 10.4 mg before the treatment vs. 28.2 ± 4.9 mg after the treatment; P < 0.001). Treatment-related side effects included hematoma in one patient, short episodes of diarrhea in three patients, and hypotension in four patients.
Conclusions: With the assistance of the navigation system, MRI-guided CPN is a safe and effective treatment approach for managing the upper abdominal pain in patients with unresectable pancreatic cancer.

Keywords: Celiac plexus neurolysis, interventional magnetic resonance imaging, navigated open magnetic resonance imaging system, optical tracking


How to cite this article:
Jin G, Qiu X, Ding M, Dai M, Zhang X. Navigated magnetic resonance imaging-guided celiac plexus neurolysis using an open magnetic resonance system for pancreatic cancer patients with upper abdominal pain. J Can Res Ther 2019;15:825-30

How to cite this URL:
Jin G, Qiu X, Ding M, Dai M, Zhang X. Navigated magnetic resonance imaging-guided celiac plexus neurolysis using an open magnetic resonance system for pancreatic cancer patients with upper abdominal pain. J Can Res Ther [serial online] 2019 [cited 2019 Sep 20];15:825-30. Available from: http://www.cancerjournal.net/text.asp?2019/15/4/825/264287




 > Introduction Top


Pancreatic cancer is an extremely fatal primary malignant neoplasm and its incidence has increased over the past few decades. Fewer than 30% of patients are diagnosed at the surgically resectable stage because of the high malignancy, invasive growth, and propensity of early metastasis, with the overall 5-year survival rate <5%.[1],[2] Visceral pain is present in over 70% of pancreatic cancer patients at the time of diagnosis and gradually deteriorates to a level that is difficult to be controlled by administration of pain relief medicine, which represents the most important and challenging palliative care for patients with advanced pancreatic cancers.[3],[4] Despite the availability of improved nonsteroidal anti-inflammatory drugs and opioid analgesics, a high dose of such drugs still cannot provide adequate analgesia, and on the other hand, the dosage of analgesia drugs cannot be unlimitedly increased due to the intolerable adverse effects.[5] Thus, a more effective pain-relieving approach is highly demanded for the patients with medication-resistant pain.

Celiac plexus neurolysis (CPN) is a technique that can potentially improve pain control in patients with pancreatic cancer while reducing the dosage of opioid drugs and the drug-related side effects accordingly. Since its establishment, CPN has been performed percutaneously under the guidance of fluoroscopy, computed tomography (CT), and magnetic resonance imaging (MRI).[6],[7],[8] Interventional MRI takes advantage of the multiple unique features of MRI, such as good temporal resolution, excellent issue contrast, spatial resolution, and real- or near real-time imaging, enabling the excellent identification of critical structures, such as vessels and nerves, without contrast injection.[9],[10],[11] In addition, both patient and doctor avoid exposure to ionizing radiation during the whole procedure of the treatment.[12] The development of magnetic resonance (MR) hardware and software makes MRI scan much faster and more flexible in accessing the target.[13],[14] An easy-to-use optical navigation system has been used in operation.[15],[16] It could facilitate the fast and accurate determination of the skin entry point, precise needle trajectory planning, and the lesion targeting in one step, which simplified MRI-guided procedures.[17]

The purpose of this study was to evaluate the feasibility, safety, and effects of navigated MR-guided CPN as a pain alleviation technique to treat pancreatic cancer-induced severe chronic abdominal pain.


 > Materials and Methods Top


Study population

This is a retrospective study. From January 2013 to October 2017, 23 patients (15 males and 8 females; mean age of 56.8 ± 8.8 years) were referred to our department for CPN. Specific inclusion criteria were minimum age of 18 years, chronic abdominal pain caused by advanced pancreatic cancer, insufficient pain relief by analgesic medication, and access to celiac trunk available through a posterior puncture determined by preprocedure MRI or CT. This study was reviewed and approved by the Institutional Review Board, and written informed consent was obtained from each patient.

Exclusion criteria were age under 18 years, debilitated general patient condition, uncorrectable coagulation disorder (platelet count <50,000/μL or international normalized ratio [INR] >1.5), and general contraindications for MRI.

Navigation and magnetic resonance imaging system

All interventions were performed in a 0.4 T fully open MRI scanner with horizontal magnet gap (EMT-4000F, EMT, Shanghai, China). The MRI system includes an additional workstation, a flat screen monitor, and a wireless mouse/keyboard for sequence initiation and navigation system control inside the MRI room. A flexible single-loop surface coil (EMT, Shanghai, China) with a 30/40-cm inner diameter was used for all procedures.

Navigation systems include a movable three-dimensional (3D) infrared camera (Polaris Spectra ®, NDI, Waterloo, Canada) and optical markers fixed on the MR scanner, patient table, and the needle holder. The needle track leading to the target was preplanned with the assistance of an optical tracking system (EMT-100, EMT, Shanghai, China).

Interventional procedure

All the patients were trained to keep breathing slowly and steadily before the operation. A patient was placed on the MRI table in prone position, with the flexible single-loop surface coil fixed on the back between T10 and L2 levels. Axial, coronal, and sagittal spin-echo (SE) T1-weighted and fast SE T2-weighted images were acquired to evaluate the anatomy of the target area and identify the crucial structures around the celiac plexus. Subsequently, images acquired were transferred to the workstation of the navigation system, then the procedural route and the points of puncture site and target were settled in the prescanned images. In brief, the position, orientation, and motion of the coaxial needle can be real-time tracked in a multiplanar virtual MRI that is displayed on the screen [Figure 1]. After motion calibration, the bed was moved out of the imaging field of interest.
Figure 1: Screenshot of the navigation scene. The red points indicate the puncture target, the yellow lines indicate the needle, and the dotted lines show its trajectory to the target

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All procedures were performed under local anesthesia with 5–10 ml 1% lidocaine. Then, an 18G MR-compatible coaxial needle was advanced to target the celiac plexus under a real-time virtual guidance of the optical tracking system. Once the needle was advanced to the target along the preplanned trajectory, the patient table was moved back to the same position where the first set of MR images was acquired. The Flash Low Angle Shot (FLASH) sequence was repeated to identify the position of the puncture needle.

After confirming the needle was in position, 2 ml of 1% lidocaine was first injected through the coaxial needle as a test dose. If the patient felt pain relief within 5 min, the injection was performed with 20 ml mixture solution of absolute ethanol with 1% bupivacaine and Gadolinium-Diethylenetriaminepentaacetic Acid (Gd-DTPA) at a volume ratio of 6.5:3:0.5 into the retroperitoneal space surrounding the celiac plexus. Axial and sagittal SE T1-weighted images were acquired to evaluate the diffusion range of the mixture. If the diffusion of the ethanol was not found satisfactory, a second puncture was performed on the opposite side of the celiac plexus. Before the withdrawal of the needle, 2–5 ml 0.9% saline solution was injected in the retroperitoneal space to prevent possible ethanol leak from the needle into adjacent tissue. The parameters of the MRI sequences used for the interventional procedures are shown in [Table 1].
Table 1: Image parameter in the 0.4 T open magnetic resonance imaging

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Treatment effect and complication evaluation

Major complications and pain relief were observed and evaluated over 3 months of posttreatment follow-up. Major complications, such as pneumothorax, chylothorax, or paraplegia, were defined as procedure-related fatality or incidents requiring surgical or medical intervention or prolonged hospital care (>1 day).

The pain intensity of each patient was scored by one investigator in our group using the 11-point visual analog scale (VAS), ranging from 0 to 10 (0 = no pain and 10 = maximum pain intensity) 1 day before the treatment and at the time point of 1 day, 1 month, and 3 months after the interventional procedure. The pain relief with >3-point pain score decrease compared with the baseline was defined as the positive response; those with a lower extent of pain relief were defined as nonresponders. The daily opioid consumption before the treatment and 1 month after the treatment was documented.

Statistical analysis

Statistical analyses were performed using the SPSS 16.0 (IBM, New York, USA) for Windows. The complete data from the treated patients who were completely followed up over the time course of 3 months were analyzed. The last-observation-carried-forward method was used for missing data. Statistical analysis was performed using the Wilcoxon signed-rank test for comparing the VAS scores and analgesic drug consumptions at the time point before the treatment and 1 day and 30 days after the treatment. The data are presented as mean ± standard derivation. P<0.05 indicates the statistical significance.


 > Results Top


Twenty-three patients, including 8 females (34.8%) and 15 males (65.2%), with a mean age of 57 years (range: 48–76 years) were treated with CPN and followed up for 3 months. Three patients received the bilateral CPN which was completed within a mean procedure time of 37 min (range: 33–42 min) and 20 patients were treated with unilateral CPN within a procedure time of 20 min (range: 18–25 min). The demographic characteristics and case-specific data are presented in [Table 2].
Table 2: Clinical characteristics

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FLASH sequence images excellently depicted the advancement of the needle along the planned trajectory and localized the needle tip in the targeted area [Figure 2]a, [Figure 2]b, [Figure 2]c. Under the monitoring of T1-weighted MRI, CPN was successfully performed in all the 23 patients, manifesting as the distribution of the injected agents in the areas surrounding the celiac plexus [Figure 2]d and [Figure 2]e.
Figure 2: Magnetic resonance images of a 56-year-old woman who underwent percutaneous celiac plexus neurolysis. (a) Flash Low Angle Shot (FLASH) transverse image shows the position of the needle and the tip (arrow) reaching the target area between abdominal aorta and inferior vena cava. (b) FLASH sagittal image shows the position of the needle and the tip (arrow) reaching the target area. (c) T1-weighted spin-echo transverse image reconfirms the needle position (arrow). (d) T1-weighted spin-echo transverse image before injection of ethanol. (e) T1-weighted spin-echo transverse image after injection of ethanol. High signal intensity (arrowhead) shows the ethanol distribution

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No major complications occurred during or after the intervention. A minor complication was seen in one patient, who developed a small hematoma at the needle puncture site. A short period of hypotension occurred in four patients which was resolved by the intravenous infusion of 0.9% saline. Short episodes of diarrhea occurred in three patients, which disappeared spontaneously within 1–2 days with a routine postprocedure care.

All patients had an average pain score of 8.8 ± 1.0 prior to the procedure and exclusively required the pain relief medication using nonsteroidal anti-inflammatory drugs and opioid analgesics. The average VAS score decreased to 2.9 ± 0.9 1 day after the interventions, and complete pain resolution was observed in two patients who stopped taking the pain medications 1 month and 3 months after the treatment (P < 0.05). The VAS score returned to 4.2 ± 1.7 and 4.7 ± 1.8, respectively, at the time point of 1 and 3 months after the intervention, which was significantly higher than that at the time point of 1 day after the intervention but still significantly lower compared with baseline (P < 0.05) [Figure 3]. Four patients died due to disease progression, among whom one patient had a completely effective neurolysis, two patients experienced a pain reduction <50% ([VASbefore treatment − VASafter treatment]/VASbefore treatment), and one patient achieved a pain reduction <30% ([VASbefore treatment − VASafter treatment]/VASbefore treatment).
Figure 3: The average visual analog scale score before intervention (baseline) was 8.8 ± 1.0. The score decreased to 2.9 ± 0.9 1 day after intervention. 1 month and 3 months later, the score re-increased to 4.2 ± 1.7 and 4.7 ± 1.8 separately which was significantly higher than 1 day after intervention, while still significantly lower compared with baseline. *P < 0.05 versus baseline. #P < 0.05 versus 1 day. P was calculated using the Wilcoxon signed-rank test

Click here to view


Opioid consumption was recorded in 21 patients. The opioid consumption in 18 patients significantly decreased (52.3 ± 10.4 mg vs. 28.2 ± 4.9 mg, P < 0.001), and 3 patients maintained the analgesic drug consumption during the period of 1 month after the procedure compared with the drug consumption before the intervention [Figure 4]. The opioid consumption of the other two patients was not included in the analysis due to the irregular intake of pain relief medicines.
Figure 4: The average level of opioid consumption before and after intervention (52.3 ± 10.4 mg vs. 28.2 ± 4.9 mg). *P < 0.001 versus before intervention. P was calculated using the Wilcoxon signed-rank test

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 > Discussion Top


We successfully performed CPN for 23 patients with medication-resistant abdominal pain caused by unresectable pancreatic cancer using 0.4 T open MR system with the assistance of optical 3D navigation system. Among the patients with successful injection of neurolysis agents in the areas surrounding the celiac plexus, all patients achieved the pain relief, showing as the significant decrease of the average consumption of analgesic medicine and the reduced VAS score over the time course of 3 months after the interventional procedures. A few incidences of minor adverse effects were observed after the procedures, which were resolved using appropriate medications.

Fluoroscopy and transabdominal ultrasound (US) as well as CT have been the mostly used imaging modalities to guide neurolytic celiac plexus ablation.[18],[19],[20],[21] Considering the wide range of abdominal anatomical variations, especially in the pancreatic cancer patients with retroperitoneal metastases, it is still a challenge to simplify the needle puncture and accurately position the need tip in the targeted areas in a timely fashion using the anatomical landmarks as the reference.[22] Frequent puncture attempts are needed to adjust the entry point and the trajectory of the needle using fluoroscopy or CT guidance, which pose the risk of untargeted punctures and the ionizing radiation hazard to both patients and the interventionists. In our studies, under the assistance of 3D optical navigation system, we used a 0.4 T MRI to guide the needle entry and the advancement of the needle toward the target area and accurately position the needle tip in the celiac plexus area.

Hol et al.[8] reported a small cohort of patients who received the MRI-guided celiac plexus block for the nononcologic pain in 2000. In their study, they used a 0.5 T semi-open horizontal MR system. Akural et al.[23] performed 13 celiac plexus ablations in patients with cancer-induced chronic abdominal pain. In their reported study, a 0.23 T open MR scanner with optical navigation was used for guiding the needle puncture. Using a similar MR system, Liu et al.[24] reported 39 cases of MR-guided CPN in patients with pancreatic cancer-caused severe pain. We used a 0.4 T open MRI systems for the procedures, which offered the relatively higher field magnetic strength, conventional MRI sequences, as well as the fast imaging sequences, to facilitate the real-time guidance of the needle puncture and the accurate placement of the needle tip in the target. With the assistance of optical navigation system equipped with the navigation software EMT-100, the interventionist could carry out the puncture outside the magnetic field and the needle advancement can be made along the accurately planned needle trajectory toward the target efficiently.

Meta-analyses included 1117 patients, 63% of them with pancreatic cancer, in whom fluoroscopy-, US-, or CT-guided neurolysis was performed. Pain alleviation came to effect 2 weeks after the intervention, 90% of patients maintained the pain relief over the period of duration for 3 months after the procedure, and 70%–90% of patients experienced pain relief till the death.[25] Another meta-analysis included six randomized controlled trials of 358 patients treated with CT-guided CPN, which showed a limited effect of pain relief at 4 and 8 weeks after the procedure, but some benefits were brought to the patients, including significantly reduced opioid consumption and lower incidences of procedure-related side effects.[26] In consistence with the outcomes of the above-mentioned studies, our study showed that the average VAS score significantly decreased immediately after the intervention and maintained at the significantly lower level over the time course of postprocedure follow-up. The consumption of opioid significantly decreased 1 month after the intervention as well.

The patients in our study experienced minor adverse effects after the procedures, which were resolved by appropriate medications.[6],[18] No major complications such as paraplegia and injuries to abdominal organs were observed. One patient developed a small hematoma at the needle puncture site which may be due to the impaired liver function due to the widespread pancreatic cancer metastases, even though the INR and prothrombin time were at the normal level. Prolonging the compression time may avoid the occurrence of hematoma. A short period of hypotension in four patients was recovered after an administration of intravenous saline infusion.

This study has some limitations. First, the number of patients was small. Second, we did not compare the outcome of patients with that of the patients who were treated with fluoroscopy- and CT-guided CPN, regarding the procedure time, adverse effects, and the effect of pain palliation. The life quality improvement of the patients was not evaluated. Given the poor prognosis and short life expectancy of the patients with advanced pancreatic cancer, we did not perform the long-term postprocedural follow-up. A controlled, randomized study with larger patient populations is necessary to confirm the long-term efficacy and safety of using navigated MRI-guided CPN for the patients with medication-resistant chronic abdominal pain.


 > Conclusions Top


With the assistant of navigation device, MRI-guided CPN is a safe and effective treatment for managing the severe pain in patients with unresectable pancreatic cancer.

Financial support and sponsorship

The study was financially supported by Innovation Funding of Renji Hospital (No. PYXJ516010) and Shanghai Science and Technology Innovation Fund (19441907000).

Conflicts of interest

There are no conflicts of interest.



 
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