Post-mastectomy Syndrome: Identification Katarzyna Ibanez, MD Assistant Attending Physiatrist...
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Transcript of Post-mastectomy Syndrome: Identification Katarzyna Ibanez, MD Assistant Attending Physiatrist...
Post-mastectomy Syndrome:Identification
Katarzyna Ibanez, MD Assistant Attending PhysiatristMemorial 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 2015www.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 2015www.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 2015www.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 cancerNeuromuscular
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 CancerFrequency of Current Self-Reported Symptoms by Year Shoulder
StiffnessArm Swelling Arm
NumbnessArm 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
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 post-mastectomy 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 post-mastectomy 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 SyndromeRisk 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 syndromePsychosocial 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 syndromeImpact 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