Transcript The Breast - Rackcdn.com

Post-mastectomy Syndrome:
Identification
Katarzyna Ibanez, MD
Assistant Attending Physiatrist
Memorial Sloan-Kettering Cancer Center
Disclosures:

None
Objectives:

Cancer statistics

Upper body morbidity after breast cancer

Define Post-mastectomy Syndrome

Discuss epidemiology and etiology of symptoms

Differential diagnosis for Post-mastectomy
Syndrome
U.S. Cancer Statistics

14.5 million with hx of cancer alive in 2014

1,658,370 new cancers expected to be
diagnosed in 2015

589,430 expected to die of cancer in 2015

Cancer death accounts for nearly 1 in 4 deaths

Direct medical costs for cancer treatment was
$88.7 billion in 2011
Cancer Facts and Figures 2015
www.cancer.org
U.S. Breast Cancer Statistics

2.5 million breast cancer survivors

1 in 8 women affected by breast cancer

234,190 new cases expected to be diagnosed in
2015


231,840 women

2,350 men
40,730 deaths expected in 2015

40,290 women

440 men
Cancer Facts and Figures 2015
www.cancer.org
U.S. Breast Cancer Statistics

Most commonly diagnosed cancer in women
(except for skin cancer)

Second most common cause of cancer death
in women (after lung cancer)

For all stages combined:

5 year survival rate 89%

10 year survival rate 83%

15 year survival rate 78%
Cancer Facts and Figures 2015
www.cancer.org
Breast cancer treatment

Surgery

Lumpectomy or mastectomy

Sentinel lymph node biopsy or axillary lymph node dissection

Radiation

Hormonal therapy

Chemotherapy

ACT (Adriamycin, Cyclophosphamide, Taxol)

CMF (Cyclophosphamide, Methotrexate, Fluorouracil)
Morbidity and functional impairments as a
consequence of breast cancer treatment is common
Upper body morbidity after
breast cancer
Neuromuscular
Cervical radiculopathy
Brachial plexopathy
Polyneuropathy
Mononeuropathies
Post-mastectomy syndrome
Intercostobrachial neuralgia
Complex Regional Pain Syndrome
Upper body morbidity after
breast cancer
Musculoskeletal
Post-surgical pain
Rotator cuff disease/Tendinosis/Adhesive Capsulitis
Arthralgias and Myalgias
Lymphovascular
Lymphedema
Axillary web syndrome
Deep vein thrombosis and Post-thrombotic syndrome
Integumentary
Cellulitis
Radiation dermatitis
Upper body morbidity after
breast cancer

Associated with alteration in use and function of the upper
body

Has adverse physical, psychosocial and social ramifications
which influence daily life and quality of life

10-64% of women report upper body symptoms between 6
months and 3 years after treatment

Pain reported in 12 to 51% of patients

20% develop lymphedema
Hayes, S. C., et al. (2012). "Upper-body morbidity after breast cancer: incidence and evidence for
evaluation, prevention, and management within a prospective surveillance model of care." Cancer
118(8 Suppl): 2237-2249.
Upper body morbidity after
breast cancer
Hayes, S. C., et al. (2012). "Upper-body morbidity after breast cancer: incidence and evidence for
evaluation, prevention, and management within a prospective surveillance model of care." Cancer
118(8 Suppl): 2237-2249.
Breast Cancer Treatment
Sequelae
Schmitz KH, Speck RM, Rye SA, DiSipio T, Hayes SC. Prevalence of breast cancer
treatment sequelae over 6 years of follow-up: the Pulling Through Study. Cancer.
Apr 15 2012;118(8 Suppl):2217-2225.
Upper Extremity Pain in Breast Cancer
Frequency of Current Self-Reported Symptoms by
Year
Shoulder
Stiffness
Arm Swelling
Arm
Numbness
Arm Pain/Ache
1.0-1.9 yrs.
16.3
20.4
61.2
38.8
2.0-2.9 yrs.
20.7
24.6
65.9
44.9
3.0-3.9 yrs.
21.8
28.3
54.2
42.5
>4.0 yrs.
22.9
28.8
55.9
44.1
McCredie, et al. The Breast. 2001;10:515-22.
Post-mastectomy
syndrome - Definition

Chronic neuropathic pain condition that can occur
following surgery to the breast

The exact mechanism is unknown but thought due to nerve
damage, particularly those involving dissection of the axilla

Can start anytime after surgery but persists beyond normal
healing time (~3months)

Pain neuropathic in character

Pain located in the chest wall, axilla, arm, or shoulder on the
affected side
Post-mastectomy
syndrome - Continued

Symptoms vary depending on the type of surgery and the
adjuvant treatment received as well as the individual patient

The extent of treatment consistently identified as a significant
risk factor

Affects as many as 40% of patients
Post-mastectomy
Syndrome – Continued (2)

Symptoms include one or more of the following:

Pain (nociceptive and neuropathic, phantom, CRPS)

Sensory changes (paresthesias, dysesthesias, allodynia)

Spasms

Muscle atrophy

Muscle weakness

Capsular contracture

Limited range of motion

Edema/lymphedema – axilla, chest wall, breast, arm

Cording
Pain following mastectomy
and breast reconstruction

i.
Incidence of pain

31% with mastectomy alone

49% with mastectomy and reconstruction
o
With implants – 53%
o
Without implants – 30%
Wallace MS, Wallace AM, Lee J, Dobke MK. Pain after breast
surgery: a survey of 282 women. Pain. Aug 1996;66(2-3):195-205.
Capsular contracture

Immune response to the foreign object

Tightly woven collagen fiber capsule tightnens and squeezes
the implant

Painful and disfiguring

Baker capsular contracture scale

Grade I — the breast is normally soft; appears natural

Grade II — the breast is a little firm, appears normal

Grade III — the breast is firm and appears abnormal

Grade IV — the breast is hard, painful to the touch, and appears
abnormal
Axillary web syndrome
Also known as cording

Tight fibrous cords in the axilla that can extend along the arm
to the antecubital fossa and forearm

Believed to be due to disruption of lymphatic vessels and
veins

Typically self-limited but may persist, cause pain and
tightness
Post-mastectomy syndrome

Associated signs may include:

Visible muscle spasms

Myokymia

Muscle atrophy

Muscle weakness

Radiation changes

Capsular contracture

Limited ROM

Edema/lymphedema

Cording

Tenderness

Disfigurement
Possible etiologies of postmastectomy pain

Axillary lymph node dissection

Sentinel lymph node dissection1

Intercostobrachial nerve injury/entrapment

Axillary hematoma post surgery

Severe acute post-operative pain
Miguel R, Kuhn AM, Shons AR, et al. The effect of sentinel node selective axillary lymphadenectomy on the
incidence of postmastectomy pain syndrome. Cancer Control. Sep-Oct 2001;8(5):427-430.
Possible etiologies of postmastectomy pain

Phantom breast pain



May affect 23% of patients
Neuroma formation

Focal area of sensitivity commonly along borders
of incision

Rule out local recurrence first
Incisional pain, scar tissue adherence
Post-mastectomy syndrome –
additional etiologies

Uncontrolled dystonic muscle spasms and
hypertonicity of the chest wall musculature

Tissue ischemia and nerve compression

Pectoralis

Serratus anterior

Latissimus dorsi
Post-mastectomy Syndrome
Risk Factors

Younger age

Unmarried

Type/extent of surgery

Radiotherapy

Chemotherapy

Preoperative anxiety

Severe postoperative pain

Greater postoperative analgesic use
Tasmuth T, von Smitten K, Hietanen P, Kataja M, Kalso E. Pain and other
symptoms after different treatment modalities of breast cancer. Ann Oncol.
May 1995;6(5):453-459..
Post-mastectomy syndrome
Psychosocial factors

Additional risk factors for persistent pain
after breast cancer surgery

Catastrophizing

Anxiety

Depression

Somatization

Sleep Quality
Schreiber, K. L., et al. (2014). "Predicting, preventing and managing persistent pain after
breast cancer surgery: the importance of psychosocial factors." Pain Manag 4(6): 445-459.
Post-mastectomy syndrome
Impact on Psychosocial Functioning

Chronic pain affects lives

slightly: 50%

at least moderately: 25%

Limited activities due to pain: work, exercise, sleep,
socializing, intimacy

Greater psychological or psychiatric morbidity,
depression and anxiety
Tasmuth T, von Smitten K, Hietanen P, Kataja M, Kalso E. Pain and other symptoms after different
treatment modalities of breast cancer. Ann Oncol. May 1995;6(5):453-459.
Stevens PE, Dibble SL, Miaskowski C. Prevalence, characteristics, and impact of postmastectomy pain
syndrome: an investigation of women's experiences. Pain. Apr 1995;61(1):61-68.
Jung BF, Ahrendt GM, Oaklander AL, Dworkin RH. Neuropathic pain following breast cancer surgery:
proposed classification and research update. Pain. Jul 2003;104(1-2):1-13.
Post-mastectomy Syndrome –
Differential Diagnoses

Tumor recurrence

Paraneoplastic or chemotherapy induced
neuropathy

Plexopathy

Rib fracture

Intraparenchymal lung pathology

Thoracic nerve root impingment

Intercostal neuralgia

Post-herpetic neuralgia