Pain syndromes in patients with cancer

Prof. Miroslava Pjevic

Pain syndromes in patients with cancer

ACUTE CANCER PAIN SYNDROMES

CHRONIC CANCER PAIN SYNDROMES

ACUTE CANCER PAIN SYNDROMES

Acute pain associated with diagnostic and therapeutic procedures

Acute pain associated with anticancer therapies

Acute pain associated with malignant disease indirectly (infection, myalgia, decubitus)

Acute pain caused by tumor directly (intratumoral bleeding, pathological vertebral body fracture, acute bowel/ureteric obstruction)

ACUTE PAIN SYNDROMES

Cherny NI, Portenoy RK,1994.

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(cont)

ACUTE PAIN SYNDROMESCherny NI, Portenoy

RK,1994.

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*

(cont)

Painful mucositis (5 - 15%)

Oral / pharyngeal

Oesophageal

Gastrointestinal (dyspepsia and diarrhoea)

Myeloablative chemotherapy and radiotherapy that precede bone marrow transplantation (40-100%) Pain after 3-5 d, max 7-10 d

Radiotherapy - head and neck (80-100%)

strong pain at the end of 2nd week, max 4th week

Persistent pain for about 2-3 weeks after radiotherapy

Risk of infection (candida, herpes simplex)

Incident BTP by taking food and swallowing

CHRONIC CANCER PAIN SYNDROMES Tumor related pain syndromes

Pain syndromes of the bones

Pain syndromes of the viscera

Pain syndromes associated with neural tissue

Pain syndromes associated with cancer therapy

CHRONIC

PAIN

SYNDROMES

Cherny NI, Portenoy RK,1994

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CHRONIC

PAIN

SYNDROMES

Cherny NI, Portenoy RK,1994

(cont)

CHRONIC

PAIN

SYNDROMES

*

Cherny NI, Portenoy RK,1994

(cont)

Bone pain Most common cause of chronic and progressive pain in the

cancer population is tumor infiltration of bone

primary (myeloma multiplex) Bone metastases/lesions

Bone pain: dull or aching, deep, often constant, especially strong at night, well localised (focal), multifocal or generalized (multiple bony metastases)

Early recognition (history, clinical finding, plain X-ray, “bone scan”, CT/ MRI)

Bone metastases

Tumor infiltration of bone Lung ca 64% Breast ca 50-85% Prostate ca 60-85% Kidney ca 28-60% Urin. bladder ca 42% Gl thyroid. ca 28-60%

Multiple sites or localised

Vertebrae Pelvis Femur Ribs Base of skull

Bone is the most common site of tumor metastases

Pain due to bone metastases

More often painful (60-80%)

Mechanical periosteum distortion (streching or pulling)

Tumor compression or infiltration of adjacent soft tissues, vascular structures, nerves (neuropathic/mixed pain)

Associated inflammation

Associated muscle spasms

Acute pain exacerbations (pathological fracture, EC of the spinal cord)

Increased with activity-incident BTP

Must be distinguished from other causes of bone pain

Dificult and chalenging pain treatment

Vertebral syndromes The vertebre are the most common sites of bony

metastases Thoracic (70%) Lumbosacral (20%) Cervical (10%)

Multiple level involvment is common (85%)

Early recognition of pain syndromes due to tumor invasion of vertebral bodies is essential

Cauda equina syndrome is the most dificult complication of vertebral metastases

Clinical recognition of epidural extension Rapid progression of back pain in a crescendo

pattern, persist at rest, worse at night

Radicular pain is later sign (compression /

infiltration of dorsal roots of spinal nerves), constant or lancinating, exacerbated by recumbency, cough, sneeze, relieved by standing, usually unilateral (cervical and l-s regions) and bilateral (thoracal region)

Epidural compression (EC) of the spinal cord (cauda equina) after period of progressive pain

Epidural compression (EC) of the spinal cord (10%)

Back PAIN = initial symptom !Important to know and start EXTENSIVE evaluation and early

diagnosis

Cauda equina is the most serious complication of vertebral body metastases and is urgent state in oncology: Weakness Sensory loss Autonomic dysfunction and reflex abnormalities Paralysis (paraplegia, quadriplegia)

Pain syndromes of the bony pelvis and hip

Common sites of bone metastases

Weight–bearing function of these bones(ambulation - incident BTP)

1. Pelvis: ischiopubic, iliosacral, periacetabular

2. Proximal femur

3. Hip joint syndrome Hip pain localised or radiates to the knee or

medial thigh, mixed pain if the lumbosacral plexus involved

Pain syndromes of the viscera

Visceral tumor infiltration with or without pleura/peritoneum involved is the second most common cause of pain in patients with cancer (mixed nociceptive and neuropathic pain)

Abdominal pain syndromes are more common:

Hepatic distension syndrome (liver capsule, vessels and biliary tract) Midline retroperitoneal syndrome (coeliac plexus) Chronic intestinal obstruction (continuous and colicky pains) Peritoneal carcinomatosis Ureteric obstruction (tumor compression/infiltration within pelvis) Cancer perineal pain (tumors of the colon, rectum, female

reproductive and genitourinary system), constant and aching pain, aggravated by sitting, standing

Pain syndromes associated with neural tissue

Pain involving the peripheral nervous system is the third common cause of pain in cancer patients

Neuropathic pain

Pain is initial symptom and should be recognized

Pain syndromes associated with neural tissue

Painful radiculopathy Painful plexopathy (cervical, brachial,

lumbosacral)

Painful mononeuropathy

Painful peripheral neuropathies

Cervical plexopathy (C1-C4)

Head and neck primary tumor infiltration/compression of the cervical plexus

Pain localised in pre/postauricular regions or anterior neck, may refer to the lateral aspect of the face or head and to the ipsilateral shoulder

Strong, aching, burning, lancinating pain, often exacerbated by neck movement or swallowing

Brachial plexopathy Brachial plexopathy

tumor infiltration: Lung cancer (Pancoast) Breast cancer Lymphoma

Upper plexopathy (c5-C6)(pain in shoulder, lateral arm, first and second

fingers) Lower plexopathy (C8 –T1)

(pain in elbow, medial forearm, fourth and fifth

fingers)

Radiation- induced brachial plexopathy

Early-onset transient plexopathy

Delayed-onset progressive plexopathy

Lumbosacral plexopathyLumbar plexus (L1-L4) and sacral plexus (L4-L5, S1-S3) tumor infiltration/compression (intrapelvic neoplasm: colorectal, cervical, lymphoma, sarcoma

Upper plexopathy (30%) Colorectal tumor Pain in the lumbar back, lower abdomen, anterolateral thigh, inguinal region, buttock, leg

Lower plexopathy (50%) Pelvic tumor: rectal, gynaecological, sarcomaPain in buttock, perineum, posterolateral leg aspect, autonomic dysfunction (intestinal, bladder), leg oedema

In

summary

Early and right identification of cancer pain syndrome

may help and simplify complex management in cancer patients