Pain relief may also be achieved with procedure-based therapy, especially in the setting of metastatic HCC. Radiotherapy has been widely shown to mitigate pain due to bone and lymph node metastases and should be regarded as safe and effective palliation for metastatic HCC symptoms.7,22 Current EASL clinical practice guidelines similarly suggest palliative radiotherapy for patients suffering from pain caused by an unambiguous bone metastasis.19 However, given its ability to relieve pain more quickly, RFA may be more effective for treating cancer-induced bone pain.23 Moreover, Kashima et al achieved pain reduction in 96.6% of patients with metastatic HCC through RFA compared to studies reporting relief in 50–90% of patients through radiotherapy. TACE has also been shown to relieve CIBP and may be preferable to radiotherapy since it also achieves palliation more quickly.8

Less conventional procedure-based therapies for HCC pain relief have also been explored. Hokotate et al9 successfully treated a Japanese patient’s metastatic HCC pain with bone cement therapy, suggesting this as a clinical avenue warranting further research. Electroacupuncture has been shown to alleviate pain in advanced HCC patients as well; however, the onset of significant pain relief was slow, which calls for supplementation with traditional analgesics for this method to be effective.24Transcranial direct current stimulation (tDCS) may prove an effective therapy to alleviate visceral HCC pain.11 Multiple sessions of tDCS over the primary motor cortex generated analgesic responses in HCC patients experiencing visceral pain, where relief appeared by the fifth session and persisted for a month. This method may be especially promising because it carries negligible risk and device application is simple. While the analgesic mechanisms of tDCS are not fully understood, resting membrane potential modulation beneath the active electrode and its effects in other parts of the pain-processing network generated by motor cortex-directed inhibition of somatosensation is thought to play a role.

CONCLUSION

HCC pain constitutes a serious concern for both patients and providers. It can markedly and negatively impact HRQoL and may result from the spread of HCC itself or LRT. While treating HCC pain can be clinically challenging due to underlying hepatic impairment, hepatologists have developed analgesic treatment recommendations to bypass the risks of toxic metabolite accumulation and to avoid aggravating hepatic decompensation. Moreover, procedure-based pain therapies such as TACE, radiotherapy, and RFA have been shown to alleviate pain caused by extrahepatic HCC spread. Less studied therapies such as electroacupuncture and tDCS have demonstrated promise and should be explored further. In light of these developments and the disparity between hepatologists and nonhepatologists regarding analgesic preference for cirrhotic patients, coordinated multidisciplinary care between providers may be the optimal route for effective pain management. When used in conjunction with methodical pain assessment, up-to-date clinician knowledge of various forms of HCC pain presentation, and proper analgesic therapy, we hope improved pain management in HCC patients may be achieved.

Disclosure

The authors report no conflicts of interest in this work.


Nathaniel Christian-Miller,1 Catherine Frenette2

1Scripps Clinical Research, Scripps, San Diego, CA, USA; 2Scripps Center for Organ and Cell Transplantation, Scripps Green Hospital, La Jolla, CA, USA 


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Source: Journal of Hepatocellular Carcinoma.
Originally published July 18, 2108.