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)

* A C U T E P A I N S Y N D R O M E S

Cherny NI, Portenoy RK,1994.

* *

Cherny NI, Portenoy RK,1994.

A C U T E P A I N S Y N D R O M E S

(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 2 nd week, max 4 th 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

*

Cherny NI, Portenoy RK,1994

S Y N D R O M E S P A I N C H R O N I C

Cherny NI, Portenoy RK,1994

P A I N S Y N D R O M E S C H R O N I C

(cont)

*

Cherny NI, Portenoy RK,1994

S Y N D R O M E S C H R O N I C P A I N

(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

Bone is the most common site of tumor metastases

Tumor infiltration of bone       Lung ca Breast ca Prostate ca Kidney ca Urin. bladder ca Gl thyroid. ca 64% 50-85% 60-85% 28-60% 42% 28-60% Multiple sites or localised      Vertebrae Pelvis Femur Ribs Base of skull

Pain due to bone metastases

 More often painful (60-80%)  Acute pain exacerbations (pathological fracture, EC of the spinal cord)  Mechanical periosteum distortion (streching or pulling)  Increased with activity incident

BTP

 Tumor compression or infiltration of adjacent soft tissues, vascular structures, nerves (neuropathic/mixed pain)  Must be distinguished from other causes of bone pain  Dificult and chalenging pain treatment  Associated inflammation  Associated muscle spasms

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

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

Pain syndromes of the bony pelvis and hip

 

1.

2.

3.

Common sites of bone metastases Weight–bearing function of these bones (ambulation - incident

BTP

) Pelvis: ischiopubic, iliosacral, periacetabular

Proximal femur 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 Peritoneal carcinomatosis (continuous and colicky pains) Ureteric obstruction Cancer perineal pain (tumor compression/infiltration within pelvis) (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 recognized symptom and should be

Pain syndromes associated with neural tissue

 Painful radiculopathy  Painful plexopathy (cervical, brachial, lumbosacral)  Painful mononeuropathy  Painful peripheral neuropathies

Cervical plexopathy (C

1

-C

4

) 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

( c 5 C 6 )

(pain in shoulder, lateral arm, first and second fingers) Lower plexopathy

(C 8 –T 1 )

(pain in elbow, medial forearm, fourth and fifth fingers)  Radiation- induced brachial plexopathy  Early-onset transient plexopathy  Delayed-onset progressive plexopathy

Lumbosacral plexopathy

Lumbar plexus (L

1 -L 4

) and sacral plexus (L cervical, lymphoma, sarcoma

4 -L 5 , S 1 -S 3

) tumor infiltration/compression (intrapelvic neoplasm: colorectal,   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, sarcoma Pain 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