7.4 (part of 13.1) Chronic cancer pain syndrome

Question 1

Name top 2 causes of chronic cancer pain syndrome

Answer 1

1. Tumor-related
2. Cancer therapy (chemo, radiation, hormontal tx, bisphosphonates, surgery)

Question 2

For tumor-related chronic pain - which are the two most common pathways?

Answer 2

Bone pain and compression of neural structures

Question 3

Which type of pain is the most common in chronic cancer pain syndrome: neuropathic vs somatic vs visceral

Answer 3

Most common to least common: somatic, neuropathic, visceral

Question 4

List three most common types of cancer to cause bone pain.

What is most common site of bony mets?

Answer 4

lung
breast
prostate

vertebrae = most common site of metastases

Question 5

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

Answer 5

T, L, C

early identification imperative as pain precedes neurological invasion/compromise

Question 6

How does atlantoaxial destruction and odontoid fracture present? (Ie location, radiation, provoking factor)

Answer 6

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

Question 7

How does C7/T1 vertebra bone invasion present? How to diagnose by imaging?

Answer 7

Pain to the intrascapular region - secure cervical and thoracic spine Xrays

Question 8

How does T12/L1 (thoracolumbar junction) vertebra bone invasion present?

Answer 8

Pain to ipsilateral iliac crest or sacroiliac joint

Question 9

How does sacrum bone invasion present?

Answer 9

Severe focal pain radiating to buttocks, perineum or posterior thights - often worse with sitting or lying (better with standing or walking)

Question 10

If patient has pain with internal rotation of hip, where might cancer have spread to?

Answer 10

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

Question 11

What is the most important determinant of the efficacy of therapy for epidural spinal cord compression

Answer 11

degree of neurological impairment at the time treatment is initiated

Question 12

Most spinal cord compresion is caused how?

Answer 12

Posterior extension of vertebral body met to the epidural space

Question 13

What % of those who are plegic due to SCC will become ambulatory again with treatment?

Answer 13

10-20%

Question 14

List LOPQRST features of back pain caused by epidural SCC

Answer 14

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

Question 15

List imaging options to assess for epidural SCC

Answer 15

MRI - preferred mode, especally for leptomeningeal mets or total spine imagine
CT

Question 16

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?

Answer 16

Paraneoplastic syndrome called hypertrophic pulmonary osteoarthopathy (HPOA)

NSCLC

Question 17

List three causes of muscle cramps in cancer patients

Answer 17

neural (eg root or plexus pathology)
muscular (eg polymyositis)
biochemical abnormality (eg low Mg)

Question 18

List LOPQRST features of headache that suggest underlying malignancy

Answer 18

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

Question 19

What are leptomeningeal mets?

Answer 19

Diffuse or multifocal involvement of subarachnoid space by met tumor

Question 20

Which cancers lead to leptomeningeal mets?

Answer 20

Non hodgkin’s lymphoma
Acute lymphocytic leukemia

(Less often in solid tumors - if occuring more likely breast or SCLC)

Question 21

List three most common symptoms associated with leptomeningeal disease

Answer 21

headache

cranial nerve palsies

radicular pain in lower back / buttocks

Question 22

What 2 tools can help guide diagnosis of leptomeningeal disease?

Answer 22

MRI (more sensitive but less specific)

CSF cytology examination

Question 23

List four treatments for leptomenigneal disease

Answer 23

chemo (systemic)
chemo (intrathecal)
radiation to involved areas
steroids

Question 24

list three locations of pain for someone with a painful cervical plexopathy (and which nerve roots are involved)

Answer 24

pre-auricular
post-auricular
anterior neck

C1-C4

WP: may involve CN V, VII, IX, X

Question 25

What are 4 causes of brachial plexopathy in cancer patients?

Answer 25

Two most common:
tumor infiltration
radiation

other:
plexus entrapment in lymphoedemetous shoulder
acute ischemia many years post axillary XRT

Question 26

which nerve roots are affected by an upper brachial plexopathy?

Where is pain experienced?

Answer 26

C5 - C6
pain in shoulder girdle, lateral arm, hand

Question 27

which nerve roots are affected by a lower brachial plexopathy? Where is pain experienced?

Is lower or upper brachial plexopathy more common?

Answer 27

C7, C8, T1
elbow, medial arm, 4th, 5th digits
note - lower more typical than upper brachial plexopathy

Question 28

Chronic radiation induced brachial plexopathies:

• What is the onset?
• What is severity of pain?
• Besides pain, what other presentations might be present?
• Diagnostic tools?

Answer 28

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)

Question 29

List four cancers associated with lumbosacral plexopathy

Answer 29

colorectal
cervical
breast
lymphoma
sarcoma

Question 30

Where does lower lumbar plexopathy occur? Where is the pain? What might you find on exam?

Answer 30

Lower L5-S1

Pain in buttocks, perineum, posterlateral thigh and leg

Weakness or sensory changes in L5, S1 and depressed ankle jerk

Question 31

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?

Answer 31

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)

Question 32

What is the preferred diagnostic procedure for lumbosacral plexopathy?

Answer 32

MRI; CT is reasonable alternative

Question 33

List 3 pain sensitive structures in/around the liver.

Nociceptive afferents from the liver travel via which 3 structures?

Answer 33

Liver capsule, blood vessels, biliary tract

Celiac plexus, phrenic nerve, lower right intercostal nveres

Question 34

Midline retroperitoneal syndrome is most commonly caused by cancer in what two structures?

Where is the pain felt?

Answer 34

• pancreatic
• retroperitoneal lymphadenopathy

pain experienced in epigastrium, lower thoracic back

Question 35

Malignant perineal pain is caused by what 3 groups of cancers

Answer 35

colorectal, female reproductive tract, distal GU system

Question 36

Large painful adrenal mets are most likely to occur from what primary malignancy?

What event can increase the pain severity of large adrenal met?

Answer 36

Lung primary

Hemorrhage can increase severity of pain

Question 37

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?

Answer 37

Osteonecrosis of the femoral head

Bone scintigraphy or MRI (MRI more sensitive and specific)

Tx: analgesics, decrease/DC steroids, surgery

Question 38

Osteonecrosis of the jaw is most commonly seen with what bisphosphonates?

How does it present?

List 2 practices to reduce the risk.

Answer 38

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

Question 39

List three surgical procedures with possible chronic pain syndromes*

Answer 39

Breast surgery pain (post mastecomy, axillary LN dissection)
Post -radical neck dissection pain
post thoracotomy pain

Question 40

How does pre-amputation pain impact the risk of phantom limb pain?

Is it more prevalent in tumor related versus traumatic amputations?

Answer 40

Phantom limb pain higher in those with long duration of pre-amputation pain

More prevalent in tumor related amputation

Question 41

What is the pathology of stump pain?

When might it occur?

How is it treated?

Answer 41

neuroma development following nerve transection

several months to years following amputation

treated with lidocaine injection into neuroma

Question 42

What are three presentations of chronic radiation induced changes to the rectum?

Answer 42

PROCTITIS with bloody diarrhea, tenesmus, cramping pain

STRICTURE causing obstruction

FISTULA to bladder or vagina

Question 43

list 4 presenting symptoms of radiation cystitis

Answer 43

frequency*
urgency*
dysuria*
hematuria*
incontinence
hydronephrosis
pneumaturia
faecaluria

Question 44

Progression of pain in any chronic cancer pain syndrome should result in ruling out what?

Answer 44

recurrence/progression of malignancy