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 !)