Cancer pain Flashcards
Name 4 sources if pain in a cancer patient
- Chemo/RT
- Diagnostic procedure
- Progression of disease
- Comorbidities
Name 6 poor prognostic factors in cancer pain management
RAPIDN rapid tolerance Alcoholism psychological (depression&anxiety) Incidental pain Delirium Neuropathic pain
Spinal cord compression comes from what two mechanisms?
- hematogenic spread to bone marrow and vertebral body collapse and epidural mass formation
- direct tumour invasion from paravertebral source (10%)
Most spinal cord compression comes from what (in adults and children) and what area is most commonly affected?
In adults - metastatases from solid tumors (lung, breast, prostate, kidney)
In children - mets from neuroblastoma, Ewing’s sarcoma, osteogenic sarcoma, and rhabdomyosarcoma
70% in thoracic spine
How does spinal cord compression present?
95% initial symptom is progressive back pain with radiculopathy
radicular pain is unilateral in C-spine and L-spine; B/L in the T-spine
L’hermitte’s sign suggestive of epidural spread
After a period of progressive pain, patient will develop weakness, sensory loss, autonomic dysfunction and reflex abnormalities
weakness, hypereflexia and spasticity are some of the first signs
Imaging in spinal cord compression?
MRI
Treatment for spinal cord compression?
- Radiation therapy - external beam radiation, brachytherapy (definitive treatment for most)
- Surgery - decompression, stabilization
- Chemotherapy - alone, adjuvant
- High dose steroids IV x one dose then oral taper
Raised ICP presentation?
Headache, cranial nerve symptoms, nausea and vomiting, or the onset of seizures.
Name three types of herniation that exist with raised ICP
Central - slow deterioration in the level of consciousness, with associated headache and focal neurologic deficits.
Uncal - rapid loss of consciousness, lateral pupillary dilatation, and ipsilateral hemiparesis
Tonsillar - occipital headache, vomiting, and hiccups followed by decreasing level of consciousness and respiratory compromise
Treatment for raised ICP?
- dexamethasone
2. if herniation imminent - IV mannitol 1-1.5g/kg
Tumour lysis syndrome (TLS) is seen in which cancers?
Burkitt’s lymphoma, acute lymphocytic leukemia, acute nonlymphocytic leukemia, and less frequently, solid tumors of small-cell type, breast cancer, and medulloblastoma
What are the metabolic abnormalities found in TLS?
hyperuricemia
hyperkalemia
hyperphosphatemia
hypocalcemia
Treatment of TLS?
Regular monitoring of electrolytes, blood-urea-nitrogen (BUN), creatinine, uric acid, phosphorus, and calcium levels, often several times a day. Hydration should exceed 3,000 mL/m²/d
What is the most common metabolic emergency seen in cancer patients?
Hypercalcemia
Hypercalcemia is seen in which cancers commonly?
breast lung kidney esophagus hematologic malignancies (notably multiple myeloma) cancer of the head and neck
Clinical manifestations of Hypercalcemia?
General: Dehydration Weight loss Anorexia Pruritus Polydipsia
Neuromuscular: Fatigue Lethargy Muscle weakness Hyporeflexia Confusion Psychosis Seizure Obtundation Coma
Gastrointestinal: Nausea Vomiting Constipation Obstipation Ileus
Genitourinary:
Polyuria
Renal insufficiency
Cardiac: Bradycardia Prolonged PR interval Shortened QT interval Wide T wave Atrial or ventricular arrhythmias
Treatments for hypercalcemia?
Gallium nitrate Plicamycin Calcitonin Bisphosphonates (etidronate, pamidronate) Hydration
Lab findings in hypercalcemia?
high serum calcium level (can be greater than 14 mg/dL)
low serum chloride level
elevated or normal serum phosphate and bicarbonate levels
elevated alkaline phosphatase levels.
Post-mastectomy pain epidemiology?
4-30% incidence
most commonly mixed nociceptive and neuropathic
Onset 2 weeks to 6 weeks post-procedure
Post-mastectomy pain pathophysiology?
- damage to intercostobrachial nerve (lateral cutaneous branch of the second intercostal nerve) - lead to neuroma
- occurs more frequently in patients with post-op complications leading to fibrosis around the nerve
- axillary dissection and reconstructive surgery is most associated with PMPS
Post-mastectomy pain clinical presentation?
- tight, constricting, burning sensation in anterior chest, axilla and medial and posterior aspects of the arm
- neuropathic elements
- Increased with arm movements
- allodynia occasionally
Post-mastectomy pain treatment?
Analgesics (NSAIDs, mild opioids, TCAs, AEDs, muscle relaxants),
CBT
Aggressive PT (to avoid adhesive capsulitis)
Interventional treatments - TPI, intercostal nerve blocks, paravertebral nerve blocks
Name cancer-related syndromes following surgery that have a high risk of persistent pain?
Post-thoracotomy pain Post-mastectomy pain Post-radical neck pain Stump pain Phantom limb pain post-surgery pelvic floor pain