Download Clinical Cases in Correctional Telemedicine

John Liszka-Hackzell, MD, PhD
University of Arizona
Anesthesiology and Pain Medicine
1- Discuss the etiology of pain in
breast cancer survivors
2- Describe the multidisciplinary
approach to pain management
assessment and treatment
3- Outline the appropriate use of pain
evaluation tools
Reasons Why Breast Cancer Patients
May Have Pain
Acute postoperative pain
- Chronic pain
- Neuropathic / Phantom Breast Pain
- Bone pain / Metastatic Cancer
-
Surgical Procedures for Breast Cancer
Radical Mastectomy (breast, skin,
pectoralis, lymph nodes)
- Modified radical Mastectomy
(pectoralis left intact)
- Lumpectomy with/without axillary
nodes.
- Lumpectomy with Sentinel node biopsy
-
Surgical Procedures for Breast Cancer
Choice of Surgical Procedure or
Technique May Influence the
Occurrence of Chronic Pain
Not shown that breast-conserving
treatment vs. modified radical
mastectomy decreases risk of chronic
pain
- Evidence of more chronic pain following
breast-conserving surgery and axillary
node dissection
-
(Wallace et al, Pain 1996)
Choice of Surgical Procedure or
Technique May Influence the
Occurrence of Chronic Pain
Increased risk of chronic pain after
breast-conserving procedure may be
related to increased use of
chemo/radiation
- Women who have breast prosthesis
may have an increased incidence of
chronic pain
-
Breast Cancer Surgery – Innervation
-Third through sixth Intercostal nerves
-Lateral cutaneous branch of T2 (ICB) –
upper, medial portion of the arm
-Lateral and anterior branches – anterior
chest, upper back
-T3 innervates the axilla, anterior and
posterior torso
-T4 and below innervates the torso. Nipple
is primarily T4
Acute Post-Operative Pain
Following Breast Surgery
Relationship between intensity of
acute post-operative pain and Chronic
post-treatment pain (Tasmuth et al,
Acta Oncol, 1997).
- Severity of acute postoperative pain is
the best predictor of chronic pain in
Breast Cancer
-
Increased Postoperative Pain
May Be Related to:
Unrecognized preoperative neuropathic
pain
- Poor postoperative pain management
- Pre-existing depression/anxiety
- Surgical technique (nerve sparing
procedures)
- Postoperative complications (infection /
bleeding)
- Pre-existing chronic pain
-
Regional anesthesia techniques in
combination with general anesthesia
may decrease the incidence of
long-term pain
Thoracic epidural
Paravertebral block
Postoperative Pain
and
Pre-emptive Pain Management
Evidence that effective preoperative and
intraoperative pain management reduces
postoperative pain
- Pre-emptive pain management may
reduce risk of chronic pain
-
Chronic Pain Following Breast Surgery
Risk Factors
-Age? <35 worse prognosis in general
-Chemo, Radiation – not associated with
Phantom breast pain, but other chronic
pains
-Chronic Pain possibly greater in
patients with pre-existing
anxiety/depression
(Tasmuth et al, Pain, 1996)
Chronic Pain Following Breast Surgery
May be seen in up to 50% of mastectomy
patients
- “Postmastectomy pain syndrome” has
four components:
1) Phantom breast pain
2) ICB neuralgia
3) Neuroma pain (scar pain)
4) Other nerve injury pains
(Jung et al, Pain, 2003)
-
Intercostobrachial Neuralgia
- Arises from the lateral cutaneous
branch of the second intercostal nerve
- Occurs more frequently with axillary
node dissection (Jung et al, Pain, 2003)
- Technically difficult to preserve the nerve
- Neuropathic pain
- Involves axilla and medial upper arm
- Neuroma formation (macro/micro)


Sensory abnormalities in the
intercostobrachial nerve distribution in
60-80% of women following breast
cancer surgery (breast conserving vs.
radical)
25% of these women will develop
intercostobrachial neuralgia
(Maunsell et al, Can J Surg, 1993)
Other Nerve Injury Pains
-Medial and Lateral Pectoral (maj/min
pectoral)
-Long Thoracic (post shoulder/scapula,
winged scapula)
-Thoracodorsal (latissimus)
-Usually spared
Chronic Pain
Distribution / Description
Nociceptive – injury to ligament, muscle
etc.
- Neuropathic. Originates in the nervous
system
- Arm, neck, shoulder, axilla, chest wall or
breast “continuation of acute pain”
- Paresthesia, Dysesthesia,
Allodynia, Hyperalgesia
-
Chronic Pain
Neuropathic Pain
Paresthesia: a sensation of tingling,
pricking or numbness
- Dysesthesia: a spontaneous or evoked
unpleasant abnormal sensation
- Allodynia: a painful response to a usually
non-painful stimulus
- Hyperalgesia: an increased sensititivity to
pain
-
Chronic Pain
Phantom Breast Pain
and Neuropathic Pain
Neuropathic pain. Damage to peripheral
nerve
- “Regeneration” Neuroma formation
- Spontaneous firing
- Often pain is sharp, shooting and burning
-
Chronic Pain
Phantom Breast Pain
and Neuropathic Pain
- Phantom pain. Not referred, but
perceived
- Different from Phantom sensation
- Sharp, often stabbing pain
- Similar to neuropathic pain
- Develops weeks to months after
procedure
-May be associated with
neuroma formation



Not well understood
Peripheral changes. Ectopic discharges
from peripheral and central neuron,
sympatheric activation and loss of
noiception
Cortical re-mapping: pre-existing pain
creates a cortical pain memory Reorganization in somatosensory cortex
following amputation
(Flor et at, Pain Clin Update, 2000)
Chronic Pain and Breast Cancer
Postoperative radiation is a risk factor for
chronic arm and breast pain
- Correlation between axillary radiation and
arm pain (Keramopoulos et al, Oncology,
1993)
- Plexus injuries
-
Chronic Pain – Prognosis
Typically decreasing over the first year
- 31% at 1-2 years to 20% at 4 years (Ivens
et al Br J Cancer, 1992)
- Chronic nociceptive pain better
prognosis than neuropathic
- Neuropathic pain / Phantom breast pain
are more chronic and problematic
- Association with depression/anxiety
-
Bone Pain / Metastatic Disease
Results in anemia, risk of infection, pain,
fractures decreased mobility
- Difficult to fully control (Mercadante,
Pain, 1997)
- May be osteolytic or osteoblastic
- Osteoblastic tumors may provide more
mechanical stability
-
Management of
Acute Post-operative Pain
Pre-emptive analgesia (block,
adjuvants) may decrease risk of
chronic pain
- Standard opioids
- Postoperative PCA
- Consider appropriate regional
anesthesia for postoperative pain
-
Management of Chronic Pain
Neuropathic Pain
Multidisciplinary approach
- Physical therapy
- Occupational therapy
- Behavioral / Pain management
- Acupuncture / Chiropractic
- Medical Management
-
Management of Chronic - Neuropathic Pain
Management of Chronic - Neuropathic Pain
Management of Chronic - Neuropathic Pain
Neuropathic Pain
Adjuvant Medications
Lyrica (Pregabalin)
- Works on Ca channels
- Approved for DPN, PHN, Fibromyalgia
- Side effects: Drowsiness, Sedation,
Blurred vision
- 300-600 mg/day (bid-tid)
-
Management of Bone Pain
Opiods may attenuate bone pain
- Biphosphonates may be helpful, however
no data suggests effect on long-term
survival (Fulfaro et al, Pain, 2001)
- COX-2 inhibitors prevents inflammatory
response, bone resorption and may
reduce tumor burden
-
Conclusion
Chronic pain seen in many patients
(Nociceptive vs. Neuropathic)
- Surgical technique
- Good peri-operative pain control
- Multidisciplinary management
- Multiple options for medical
management
-