Post on 11-Jan-2016
description
Chronic pain following breast surgery
-Do patients have to live with it ?
Dr A. Lukas
20% 26%
0 20 40 60 80 100 120
glandula parotidea
orofarynx
nasofarynx
hypofarynx
darm
lever en galwegen
pancreas
trachea, bronchus en long, thymus
mesothelioom
maligne melanoom
peritoneum
sarkomen
mamma
cervix, uerus, ovaria
penis
prostaat
nier, ureter en blaas
centraal zenuwstelsel
endocrine klieren
CUP
Lymfomen
M. Kahler
Overige
aantal patiënten
2007, n=373
2006, n=453
Patientpopulation NKI-AVL outpatient clinic
Patients with postmastectomy pain
NKI-AVL outpatient clinic
0 5 10 15 20 25 30 35 40
Shoulder pain second diagnosis (M2551)
Brachial plexus disorders (G540)
Neuralgia intercostobrachial nerve (G580)
Anterior chest-w all pain (R0789)
2006, n=60 (50%) 2007, n=42 (55%)
PMPS-Pathofysiologie-
84%74%
58%
Stevens, Pain 1995, 61
Postmastectomy pain-Definition-
deafferentation type pain syndrome
immediately or as late as many months following
surgery
shock-like pain sensations overlying a more
continuous aching and burning
accompanied by dysesthesias, phantom
sensations
worsened by (arm) movement, lying on side
natural history variable with subacute and
chronic courses possible
Prevalence of postmastectomy painAuthor Year NT Operation Follow-up incidence PMPS
Staps 1985 89 MRM ? 33%
Stevens 1995 95BCTMRM ? 20%
Tasmuth 1996 93BCTMRM 1y 32%
Wallace 1996 282
MRMMRM+ reconstructioncosmetic augmentationbreast reduction 1 y?
31%49%38%22%
Tasmuth 1996 93BCTMRM 1 y 17%
Carpenter 1998 134BCTMRM 3 y 27%
Smith 1999 408 MRM 5 y ? 43%
Macdonald(Smith) 2005 113
MRMRM+ m. pectoralis 9 y 14%
Kudel 2007 278BCTMRM 2 y 55%
1585 3 y 31%
Postmastectomy pain-classification according to Jung et al., Pain 2003
Neuralgia intercostobrachial nerve (20-
58%)
Phantom breast pain (13-44%)
Neuroma pain (23-
49%)
Other nerve injury
pains
Postmastectomy pain -Risc factors-
preoperative pain and unusual breast sensations
postoperative complications
surgical technique ( axillary dissection)
subsequent chemotherapy / radiotherapy
high intensity of acute postoperative pain
young age
psychological factors ( high levels of anxiety,
depression, catastrophizing, somatization )
There are more reasons for pain following breast surgery !
slee
pfu
nctio
ning
sexu
ality
fatigue
pension / part-time w
ork
relationship problems
reminds cancer
anxiety
Postmastectomy pain -factor-x-
Postmastectomy pain -Treatment -
Author Year NT Intervention result
Vilholm 2008 27levitiracetam 500->3000 mg/4w no pain relief
Kalso 2002 13venlafaxine 18,75->75mg/4w relief maximum pain
Kalso 1995 15amitriptylline 25->100 mg/d
50% pain relief at 50 mgNO PATIENT WANTED TO CONTINUE
Watson 1992 23capsaicine 0,075% topical /6w
improvement of pain3 PATIENTS CONTINUED
Lymphedema treatment
Physiotherapie( feel & dare ! )
Psychological support
bodyperception – perceive and accept changes
Coping (limitation, mutilation) sexualityanxiety (recurrence)afraid of pain / harm fatigue
Analgesia and nerve function following pulsed radiofrequency for
postmastectomy pain A. Lukas, H. van Tinteren, S. Linn, E. Rutgers, N. Aaronson, R.
Perez
Pulsed radiofrequency treatment of neuropathic pain
(PRF)
Non-neurodestructive minimal invasive treatment option for neuropathic pain (if conservative treatment fails)
Single intervention Possibly long-lasting effects“if it does not help it does not harm”
Analgesia and nerve function following pulsed radiofrequency for
postmastectomy pain A. Lukas, H. van Tinteren,S. Linn, E. Rutgers, N. Aaronson, R.
Perez
Does PRF reduce the intensity of PMPS
Possible mechanism of action PRFHas the type of nerve-lesion
impact on the effect of PRF
PMPS
6 months after surgery for breast cancer
Pain-intensity NRS > 4
Test block TH 1 / 6
Randomization
Exclusion
PRF TH 1 / 6 SHAM TH 1 / 6
> 5
0% p
ain
re
lief
< 50% pain relief
PRF TH 1 / 6 PRF TH 1 / 6
3 weeks
PMPS
6 months after surgery for breast cancer
Pain-intensity NRS > 4
Test block TH 1 / 6
Randomization
Exclusion
PRF TH 1 / 6 SHAM TH 1 / 6
> 5
0% p
ain
re
lief
< 50% pain relief
PRF TH 1 / 6 PRF TH 1 / 6
3 weeks
Analgesia and nerve function following pulsed radiofrequency for postmastectomy pain
A. Lukas, H. van Tinteren,S. Linn, E. Rutgers, N. Aaronson, R. Perez
ParametersParameters T0 T3w T 6w T6m T1y
Sociaepidemiological and clinical data x x
Pain intensity rest/abduction [NRS] x x x x x
Perceived effect [Likert scale] x x x x
Analgesics [daily dose] x x x x x
Adverse events & symptoms [VRS] x x x x
QST x x x x x
Impact of pain on daily living [VRS] x x x x x
Anxiety and depression [HADS] x x x x x
Health related quality of life [SF-36] x x x x x
Presumed received treatmentPresumed applied treatmentExpected effect (patient, interventionalist)
Xx
x
QST
Quantitative sensory testing - QST
Pilot met 24 patientenSTART maart 2010Patientenrecrutering: Maandag
Balie 4, LUK poli 13.00-16.00Alleen PMPS!!!!
Analgesia and nerve function following pulsed radiofrequency for postmastectomy pain
Lukas, H. van Tinteren,S. Linn, E. Rutgers, N. Aaronson, R. Perez
Chronic pain following breast surgerybothers 30% of patients
is a complex syndrome due to nerve lesion, movement disorders of the shoulder and connective tissue changes
has a lot of impact on the quality of life and recovery
needs multidisciplinary diagnosis and treatment
PRF might be a treatment option for neuropathic pain component ( as currently investigated in the AVL !)