Transcript Postmastectomy Pain Syndrome

Postmastectomy Pain
Syndrome
May 21st, 2015
Leslie S. Cavazos, MD, PGY-4
KUMC Department of Rehabilitation
Grand Rounds
 There are no financial disclosures or affiliations to
report.
Breast cancer
 The most common cancer in women worldwide.
 Greater than one million new cases diagnosed each
year.
 The five year overall survival of patients with a
diagnosis of primary breast cancer has increased to
85%. [9]
Introduction to PMPS
 Postmastectomy pain syndrome (PMPS) is classified
as a type of chronic neuropathic pain disorder.
 It can occur after breast cancer procedures;
frequently with surgeries that remove the upper
outer quadrant of the breast and/or axilla.
 PMPS can either regress or progress, it is not a static
condition.
Effects of PMPS
 The pain related to postmastectomy syndrome can be
severe enough to:
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Affect one’s ability to complete ADLs
Cause a sleep disturbance
Lead to adhesive capsulitis
Lead to complex regional pain syndrome
Incidence
 The incidence of PMPS ranges from 20 to 72%,
including nerve injury or impairment, and the chronic
pain that results from injury.
 This range of values can be explained by the variation
of definitions used to define PMPS.
 There is no standard definition of PMPS.
 Inclusion criteria are vague.
Risk Factors
 Pain itself is
multidimensional with the
complexity of
physiological, sensory,
behavioral, socioeconomic, and cognitive
components.
Postoperative Pain
 Preoperative anxiety
 Age less than 49
 Severe post-op pain was associated with developing
chronic pain.
Age at diagnosis
 Younger patients hypothetically noted to be more
sensitive to nerve damage, because they are more
sensitive to nerve damage, are less likely to tolerate
pain, and have increased anxiety.
 Younger women are commonly offered more
aggressive treatments.
Axillary radiation and neuropathic
Pain
 Neuropathic pain is a side effect of radiation therapy,
which can occur months to years after treatment.
 In a series published in the Journal of Pain published
in 2008, postoperative radiotherapy and neurotoxic
chemotherapy, along with axillary lymph node
dissection, were thought to contribute to chronic
pain in 70% of patients who were pain free after the
operation. [7]
Skin changes with radiation
Procedure Type
 An axillary node dissection can contribute to nerve
injury in PMPS. The Intercostobrachial nerves enters
the axilla and pass through the posteromedial border
of the upper arm.
 There is a higher incidence of chronic pain in patients
undergoing axillary lymph node dissection compared
to sentinel lymph node dissection.[7]
Anatomy of the chest wall and axilla
Axillar dissection
Thoracodorsal bundle
Procedure Type
 The surgical treatment approach did not associate
with PMPS. This includes a total mastectomy versus a
partial mastectomy.
 Complications such as the incidence of seroma,
hematoma, cellulitis, lymphedema, and reoperation
did not correlate with PMPS. [8]
Description of procedures
Description of procedures
 A partial mastectomy is
usually reserved for
women with stage I or II
breast cancer. It is a
breast conserving therapy
which is followed by
radiation therapy to the
remaining tissue.
 A lumpectomy (wide local
excision) removes just
the tumor and a small
cancer-free area of tissue
surrounding the tumor. If
cancer cells are found
later, the surgeon may
remove more of the
tissue. This procedure is
called re-excision.
Description of procedures
 A radical mastectomy is
the complete removal of
the breast, including the
nipple. The surgeon also
removes the overlying
skin, the muscles beneath
the breast, and the lymph
nodes.
 A less traumatic and more
widely used procedure is
the modified radical
mastectomy (MRM). With
the modified radical
mastectomy, the entire
breast is removed as well
as the underarm lymph
node. But pectoral
muscles are left intact.
Psychosocial factors
Psychosocial factors
 PMPS is associated with
psychosocial factors;
including depression,
insomnia, anxiety,
somatization, and
catastrophizing.
 Lack of physical activity is
also associated with
decreased psychosocial
well-being.
Clinical Examination
 PMPS patients commonly present with burning,
numbness, stabbing pain, electric shock,
hyperesthesia, and/or paraesthesia.
 Numbness is the #1 symptom reported in women
status post surgery for treatment of breast cancer.
 Chest wall pain, decreased ROM of the shoulder, and
decreased shoulder and grip strength.
Clinical Examination
 Sensory changes at the
post-op site.
 Decreased ROM of the
ipsilateral upper
extremity.
 Decreased shoulder
strength.
Diagnosis
 The diagnosis is made based upon a thorough
physical examination of the remaining breast, chest
wall, axilla, and upper extremity.
 A complete sensory and motor neurological
examination may reveal abnormalities in the affected
peripheral nerve distribution.
Differential Diagnosis
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Recurrent breast cancer
Metastatic breast cancer (humerous)
Breast infection/inflammation
Chemo-induced neuropathy
Lymphedema
Musculoskeletal disorders
Cervical radiculopathy
Treatment
Treatment
 Much of what is practiced currently in chronic pain
management comes from treating cancer pain.
 Choosing the appropriate therapeutic strategy is
dependent upon making the correct diagnosis of the
type of pain-neuropathic versus nociceptive.
 Common sense ain’t common.
Algorithm
 Lifestyle: Home safety checks, cane, walker, increase
in daily activity level.
 Medications: Antidepressants, calcium channel alpha
2-delta ligands, topical therapy, opioids, nutritional
supplements.
 Therapy: PT program to address stretching, increase
activity, increase ROM, desensitization program,
etc…
 Interventions: Injection of the rotator cuff tendons,
Botox of the Pec major, Serratus Anterior.
 Diagnostics: Imaging to rule out a recurrence, injury.
Medications
 Anticonvulsants: Used since the 1960s for
neuropathic pain, Gabapentin, Lyrica, and
Carbamazepine are FDA approved to treat
neuropathic pain.
 Gabapentin and Lyrica bind to the voltage-gated
calcium channel at the alpha-2 delta subunits.
 Lyrica was designed as a lipophilic GABA analog to
facilitate diffusion across the BBB.
 Side effects include dose-dependent sedation and
dizziness.
Medications
 Antidepressants: SNRIs such as Cymbalta have been
shown to be effective in the treatment of
neuropathy, fibromyalgia, chronic low back pain, and
osteoarthritis.
 Side effects include dry mouth, fatigue, constipation,
dizziness, insomnia, drowsiness, and nausea. Many
patients are concerned about weight gain.
Medications
 TCAs (Nortriptyline, Elavil, and Desipramine: None
carries a specific FDA indication for pain
management; however, they have frequently been
used for chronic pain management with success.
 Side effects include dry mouth, sedation,
constipation, orthostatic hypotension (Elavil has the
most effect), and anticholinergic symptoms.
Topical agents
 Avoid drug interactions, with minimal systemic
absorption.
 Lidocaine 5% topical ointment, Capsaicin cream, and
compounding creams are commonly used.
 Capsaicin is believed to block Substance P from
primary afferent neurons. Studies have not proven
high efficacy, but can be trialed in patients refractory
to other types of treatment.
Botox injections
Rotator cuff injections
Home exercise program
 Slowly increasing daily activity level, by staring with a
12 minute walk per day.
 Perform daily stretching of the affected shoulder, in
hopes of regaining prior ROM, and for prevention of
adhesive capsulitis.
 Stretch the muscles of the anterior chest wall.
Managing side effects of treatment
 Prescribe a bowel program, as constipation is a
common theme in chronic pain management, due to
drug side effects.
 Encourage adequate fluid intake, ideally 64 fluid
ounces per day, with some intake in the form of a
Power Aide Zero or Gatorade, to replace electrolytes.
May help reduce fatigue.
Thank you
References
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Couceiro TC, Valenca MM, et al. Prevalence of Post-Mastectomy Pain Syndrome and
Associated Risk Factors: A Cross-Sectional Cohort Study. Pain Management Nursing,
Vol 15, No 4 (December), 2014: pp 731-737.
Fabro EA, Bergmann A, Amaral e Silva B, et al. Post-mastectomy pain syndrome:
Incidence and risks. The Breast. 29 January 2012.
Meijuan Y, Zhiyou P, Yuwen T, et al. A retrospective study of postmastectomy pain
sydnrome: incidence, characteristics, risk factors, and influence on quality of life.
Scientific World Journal 2013; 2013: 159732
Belfer I, Schrieber KL, et al. Persistent Postmastectomy Pain in Breast Cancer Survivors:
Analysis of Clinical, Demographic, and Psychosocial Factors. American Pain Society. 3
May 2013.
Ilfeld BM, Madison SJ, et al. Persistent Postmastectomy Pain and Pain-Related Physical
and Emotional Functioning With and Without a Continuous Paravertebral Nerve Block :
A Prospective 1-Year Folllow-Up Assessment of a Randomized, Triple-Masked, PlaceboControlled Study. Annals of Surgical Oncology. 21 November 2014.
Mejdahl MK, Andersen KG, et al. Persistent pain and sensory disturbances after
treatment for breast cancer: six year nationwide follow-up study. BMJ. 11 April 2013.
References
7. Steegers MA, Wolters B, et al. Effect of axillary lymph node dissection on
prevalence and intensity of chronic and phantom pain after breast cancer
surgery. J Pain 2008; 9:813.
8. Schreiber KL, Martel MO, et al. Persistent pain in postmastectomy patients:
comparison of psychophysical, medical, surgical, and psychosocial
characteristics between patients with and without pain. Pain 2013; 154: 660.
9. Cronin-Fenton DP, Norgaard M, et al. Comorbidity and survival of Danish breast
cancer patients from 1995 to 2005. Br J Cancer 2007; 96: 1462-8.