Transcript Painful specific syndromes in cancer patients

Pain syndromes in patients
with cancer
Prof. Miroslava Pjevic
Pain syndromes in patients
with cancer
ACUTE CANCER PAIN SYNDROMES
CHRONIC CANCER PAIN SYNDROMES
ACUTE CANCER PAIN SYNDROMES
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Acute pain associated with diagnostic and
therapeutic procedures
Acute pain associated with anticancer
therapies
Acute pain associated with malignant disease
indirectly
(infection, myalgia, decubitus)
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Acute pain caused by tumor directly
(intratumoral bleeding, pathological vertebral body fracture, acute
bowel/ureteric obstruction)
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A
C
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T
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P
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I
N
S
Y
N
D
R
O
M
E
S
Cherny NI, Portenoy RK,1994.
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C
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T
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P
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N
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Y
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R
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Cherny NI, Portenoy RK,1994.
(cont)
Painful mucositis
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Oral / pharyngeal
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Oesophageal
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Gastrointestinal
(dyspepsia and diarrhoea)
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(5 - 15%)
Myeloablative chemotherapy and
radiotherapy that precede bone marrow
transplantation (40-100%)
Pain after 3-5 d, max 7-10 d
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Radiotherapy - head and neck (80-100%)
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strong pain at the end of 2nd week, max 4th
week
Persistent pain for about 2-3 weeks after
radiotherapy
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Risk of infection (candida, herpes simplex)
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Incident BTP by taking food and swallowing
CHRONIC CANCER PAIN
SYNDROMES
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Tumor related pain syndromes
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Pain syndromes of the bones
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Pain syndromes of the viscera
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Pain syndromes associated with neural tissue
Pain syndromes associated with cancer
therapy
C
H
R
O
N
I
C
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P
A
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N
Cherny NI, Portenoy RK,1994
S
Y
N
D
R
O
M
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S
C
H
R
O
N
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C
P
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Cherny NI, Portenoy RK,1994
S
Y
N
D
R
O
M
E
S
(cont)
C
H
R
O
N
I
C
*
P
A
I
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Cherny NI, Portenoy RK,1994
S
Y
N
D
R
O
M
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S
(cont)
Bone pain
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Most common cause of chronic and progressive pain in the cancer
population is tumor infiltration of bone
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primary (myeloma multiplex)
Bone metastases/lesions
Bone pain: dull or aching, deep, often constant, especially strong at
night, well localised (focal), multifocal or generalized (multiple bony
metastases)
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Early recognition (history, clinical finding, plain X-ray, “bone scan”, CT/ MRI)
Bone metastases
Bone is the most common site of tumor metastases
Tumor infiltration of bone
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Lung ca
Breast ca
Prostate ca
Kidney ca
Urin. bladder ca
Gl thyroid. ca
64%
50-85%
60-85%
28-60%
42%
28-60%
Multiple sites or localised
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Vertebrae
Pelvis
Femur
Ribs
Base of skull
Pain due to bone metastases
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More often painful (60-80%)
Mechanical periosteum
distortion (streching or
pulling)
Tumor compression or
infiltration of adjacent soft
tissues, vascular structures,
nerves (neuropathic/mixed
pain)
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Associated inflammation
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Associated muscle spasms
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Acute pain exacerbations
(pathological fracture, EC of
the spinal cord)
Increased with activityincident BTP
Must be distinguished from
other causes of bone pain
Dificult and chalenging pain
treatment
Vertebral syndromes
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The vertebre are the most common sites of bony metastases
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Thoracic (70%)
Lumbosacral (20%)
Cervical (10%)
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Multiple level involvment is common (85%)
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Early recognition of pain syndromes due to tumor invasion of
vertebral bodies is essential
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Cauda equina syndrome is the most dificult complication of
vertebral metastases
Clinical recognition of epidural
extension
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Rapid progression of back pain in a crescendo
pattern, persist at rest, worse at night
Radicular pain is later sign (compression / infiltration of
dorsal roots of spinal nerves), constant or lancinating,
exacerbated by recumbency, cough, sneeze, relieved
by standing, usually unilateral (cervical and l-s
regions) and bilateral (thoracal region)
Epidural compression (EC) of the spinal cord
(cauda equina) after period of progressive pain
Epidural compression (EC)
of the spinal cord (10%)
Back PAIN = initial symptom !
Important to know and start EXTENSIVE evaluation and early diagnosis
Cauda equina is the most serious complication
of vertebral body metastases and is urgent state
in oncology:
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Weakness
Sensory loss
Autonomic dysfunction and reflex abnormalities
Paralysis (paraplegia, quadriplegia)
Pain syndromes of the bony
pelvis and hip
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Common sites of bone metastases
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Weight–bearing function of these bones
(ambulation - incident BTP)
1.
Pelvis: ischiopubic, iliosacral, periacetabular
2.
Proximal femur
3.
Hip joint syndrome
Hip pain localised or radiates to the knee or medial thigh,
mixed pain if the lumbosacral plexus involved
Pain syndromes of the viscera
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Visceral tumor infiltration with or without pleura/peritoneum involved
is the second most common cause of pain in patients with cancer
(mixed nociceptive and neuropathic pain)
Abdominal pain syndromes are more common:
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Hepatic distension syndrome (liver capsule, vessels and biliary tract)
Midline retroperitoneal syndrome (coeliac plexus)
Chronic intestinal obstruction (continuous and colicky pains)
Peritoneal carcinomatosis
Ureteric obstruction (tumor compression/infiltration within pelvis)
Cancer perineal pain (tumors of the colon, rectum, female reproductive and
genitourinary system), constant and aching pain, aggravated by sitting, standing
Pain syndromes associated with
neural tissue
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Pain involving the peripheral nervous system
is the third common cause of pain in cancer
patients
Neuropathic pain
Pain is initial symptom and should be
recognized
Pain syndromes associated
with neural tissue
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Painful radiculopathy
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Painful plexopathy (cervical, brachial, lumbosacral)
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Painful mononeuropathy
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Painful peripheral neuropathies
Cervical plexopathy (C1-C4)
Head and neck primary tumor
infiltration/compression of the cervical
plexus
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Pain localised in pre/postauricular regions or
anterior neck, may refer to the lateral aspect of
the face or head and to the ipsilateral shoulder
Strong, aching, burning, lancinating pain, often
exacerbated by neck movement or swallowing
Brachial plexopathy
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Brachial plexopathy
tumor infiltration:
 Lung cancer (Pancoast)
 Breast cancer
 Lymphoma
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Radiation- induced
brachial plexopathy
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Upper plexopathy (c5-C6)
(pain in shoulder, lateral
arm, first and second fingers)
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Lower plexopathy (C8 –T1)
(pain in elbow, medial
forearm, fourth and fifth fingers)
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Early-onset
transient plexopathy
Delayed-onset
progressive plexopathy
Lumbosacral plexopathy
Lumbar plexus (L1-L4) and sacral plexus (L4-L5, S1-S3) tumor
infiltration/compression (intrapelvic neoplasm: colorectal,
cervical, lymphoma, sarcoma
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Upper plexopathy (30%)
Colorectal tumor
Pain in the lumbar back, lower abdomen, anterolateral thigh,
inguinal region, buttock, leg
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Lower plexopathy (50%)
Pelvic tumor: rectal, gynaecological, sarcoma
Pain in buttock, perineum, posterolateral leg aspect, autonomic
dysfunction (intestinal, bladder), leg oedema
In
summary
Early and right identification of
cancer pain syndrome
may help and simplify complex
management in cancer patients