7.4 (part of 13.1) Chronic cancer pain syndrome Flashcards
Name top 2 causes of chronic cancer pain syndrome
- Tumor-related
- Cancer therapy (chemo, radiation, hormontal tx, bisphosphonates, surgery)
For tumor-related chronic pain - which are the two most common pathways?
Bone pain and compression of neural structures
Which type of pain is the most common in chronic cancer pain syndrome: neuropathic vs somatic vs visceral
Most common to least common: somatic, neuropathic, visceral
List three most common types of cancer to cause bone pain.
What is most common site of bony mets?
lung
breast
prostate
vertebrae = most common site of metastases
List the following spinal areas in order of frequency of spinal mets from most to least. C, T, L spine. Why is early identification of spinal mets important
T, L, C
early identification imperative as pain precedes neurological invasion/compromise
How does atlantoaxial destruction and odontoid fracture present? (Ie location, radiation, provoking factor)
Nuchal (neck) or occipital pain, often radiating over the posterior aspect of the skull to the vertex, worse with neck flexion
Note: atlas = C1, axial = C2
Odontoid is the dens of C2
How does C7/T1 vertebra bone invasion present? How to diagnose by imaging?
Pain to the intrascapular region - secure cervical and thoracic spine Xrays
How does T12/L1 (thoracolumbar junction) vertebra bone invasion present?
Pain to ipsilateral iliac crest or sacroiliac joint
How does sacrum bone invasion present?
Severe focal pain radiating to buttocks, perineum or posterior thights - often worse with sitting or lying (better with standing or walking)
If patient has pain with internal rotation of hip, where might cancer have spread to?
Piriformis muscle
SS: incident buttock or posterior leg pain. Consider “piriformis syndrome” when classic signs of lumbar radiculopathy absent, other causes of gluteal/SI pain are ruled out
What is the most important determinant of the efficacy of therapy for epidural spinal cord compression
degree of neurological impairment at the time treatment is initiated
Most spinal cord compresion is caused how?
Posterior extension of vertebral body met to the epidural space
What % of those who are plegic due to SCC will become ambulatory again with treatment?
10-20%
List LOPQRST features of back pain caused by epidural SCC
L: Radicular pain
O: Rapid progression
P: Recumbency, cough, sneeze, strain
Q: Can be accompanied with lhermitte’s sign, weakness, sensory loss, autonoymic dysfunction (usually delayed after a period of having pain)
R: Bil if thorax, uni if cervical or lumbosacral
S: Crescendo pain
T: Constant or lancinating
List imaging options to assess for epidural SCC
MRI - preferred mode, especally for leptomeningeal mets or total spine imagine
CT
A patient presents with clubbing, periostitis of the long bones, polyarthritis.
- What is this syndrome called?
- What type of malignancy do they most likely have?
Paraneoplastic syndrome called hypertrophic pulmonary osteoarthopathy (HPOA)
NSCLC
List three causes of muscle cramps in cancer patients
neural (eg root or plexus pathology)
muscular (eg polymyositis)
biochemical abnormality (eg low Mg)
List LOPQRST features of headache that suggest underlying malignancy
L: focal or generalized
O: < 6 months duration
P: stooping, sudden head movements, valsalva
Q: throbbing or steady; associated with vomiting, confusion, abnormal neurological exam (and abscence of family history of migraine and absence of visual symptoms)
R: NA
S: mild to mod
T: sleep-related or worse in AM
What are leptomeningeal mets?
Diffuse or multifocal involvement of subarachnoid space by met tumor
Which cancers lead to leptomeningeal mets?
Non hodgkin’s lymphoma
Acute lymphocytic leukemia
(Less often in solid tumors - if occuring more likely breast or SCLC)
List three most common symptoms associated with leptomeningeal disease
headache
cranial nerve palsies
radicular pain in lower back / buttocks
What 2 tools can help guide diagnosis of leptomeningeal disease?
MRI (more sensitive but less specific)
CSF cytology examination
List four treatments for leptomenigneal disease
chemo (systemic)
chemo (intrathecal)
radiation to involved areas
steroids
list three locations of pain for someone with a painful cervical plexopathy (and which nerve roots are involved)
pre-auricular
post-auricular
anterior neck
C1-C4
WP: may involve CN V, VII, IX, X
What are 4 causes of brachial plexopathy in cancer patients?
Two most common:
tumor infiltration
radiation
other:
plexus entrapment in lymphoedemetous shoulder
acute ischemia many years post axillary XRT
which nerve roots are affected by an upper brachial plexopathy?
Where is pain experienced?
C5 - C6
pain in shoulder girdle, lateral arm, hand
which nerve roots are affected by a lower brachial plexopathy? Where is pain experienced?
Is lower or upper brachial plexopathy more common?
C7, C8, T1
elbow, medial arm, 4th, 5th digits
note - lower more typical than upper brachial plexopathy
Chronic radiation induced brachial plexopathies:
- What is the onset?
- What is severity of pain?
- Besides pain, what other presentations might be present?
- Diagnostic tools?
Onset: early or delayed (6 months to 20 years after rads)
Pain: uncommon and less severe
Other presentation: skin changes and lymphedema
Diagnosis: CT/MRI (radiation fibrosis) and EMG (widespread myokymia)
List four cancers associated with lumbosacral plexopathy
colorectal
cervical
breast
lymphoma
sarcoma
Where does lower lumbar plexopathy occur? Where is the pain? What might you find on exam?
Lower L5-S1
Pain in buttocks, perineum, posterlateral thigh and leg
Weakness or sensory changes in L5, S1 and depressed ankle jerk
Where does upper lumbar plexopathy occur? Where is the pain? What might you find on exam?
Between upper and lower lumbar plexopathy, what is more common?
Upper L1-L4
Pain in lower abdo, lower back or iliac crest
Sensory/motor/reflex changes in L1-L4 distribution
Lower plexopathy more common
—-
Exam:
Tone, power, reflex, sensation (TPRS)
What is the preferred diagnostic procedure for lumbosacral plexopathy?
MRI; CT is reasonable alternative
List 3 pain sensitive structures in/around the liver.
Nociceptive afferents from the liver travel via which 3 structures?
Liver capsule, blood vessels, biliary tract
Celiac plexus, phrenic nerve, lower right intercostal nveres
Midline retroperitoneal syndrome is most commonly caused by cancer in what two structures?
Where is the pain felt?
- pancreatic
- retroperitoneal lymphadenopathy
pain experienced in epigastrium, lower thoracic back
Malignant perineal pain is caused by what 3 groups of cancers
colorectal, female reproductive tract, distal GU system
Large painful adrenal mets are most likely to occur from what primary malignancy?
What event can increase the pain severity of large adrenal met?
Lung primary
Hemorrhage can increase severity of pain
A patient is treated with high dose steroids and develops pain in the knee and thigh, worse with movement.
- What pathology might be causing this?
- How is this investigated?
- How is it managed?
Osteonecrosis of the femoral head
Bone scintigraphy or MRI (MRI more sensitive and specific)
Tx: analgesics, decrease/DC steroids, surgery
Osteonecrosis of the jaw is most commonly seen with what bisphosphonates?
How does it present?
List 2 practices to reduce the risk.
IV bisphosphonates containing nitrogen (pamidronate, zoledronate)
Presents with local pain, soft tissue swelling, loose teeth
dental and panoramic XR prior to tx
complete required dental work prior to tx
educate patient on importance of good dental hygiene
List three surgical procedures with possible chronic pain syndromes*
Breast surgery pain (post mastecomy, axillary LN dissection)
Post -radical neck dissection pain
post thoracotomy pain
How does pre-amputation pain impact the risk of phantom limb pain?
Is it more prevalent in tumor related versus traumatic amputations?
Phantom limb pain higher in those with long duration of pre-amputation pain
More prevalent in tumor related amputation
What is the pathology of stump pain?
When might it occur?
How is it treated?
neuroma development following nerve transection
several months to years following amputation
treated with lidocaine injection into neuroma
What are three presentations of chronic radiation induced changes to the rectum?
PROCTITIS with bloody diarrhea, tenesmus, cramping pain
STRICTURE causing obstruction
FISTULA to bladder or vagina
list 4 presenting symptoms of radiation cystitis
frequency*
urgency*
dysuria*
hematuria*
incontinence
hydronephrosis
pneumaturia
faecaluria
Progression of pain in any chronic cancer pain syndrome should result in ruling out what?
recurrence/progression of malignancy
