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
Treatments with evidence for phantom limb pain?
Gabapentin Methadone Clonazepam Probably Canadian NeP guidelines TENS SCS
Give examples of chemotherapy related pain syndromes:
mucositis peripheral neuropathy bone pain headaches osteonecrosis visceral pain (pancreatitis)
Give examples of Radiation therapy related pain syndromes:
radionecrosis brachial plexopathy lumbosacral plexopathy myelopathy fibrosis chronic mucositis chronic esophagitis chronic pharynigitis chronic proctitis
Name some common pain management problems particular to cancer pain:
- chemotherapies can cause painful syndromes
- renal dysfunction from chemo may preclude use of NSAIDs
- common drug-drug interactions
- anti-coagulation issues for interventional pain management
- significantly more psychological disorders
- significant comorbid sleep disturbance
- prognosis changes management dramatically
What are the indications for surgical management in the treatment of cancer pain?
Headache - obstructive hydrocephalus Bone pain - pathological fracture Dysphagia - esophageal obstruction Abdominal distention - ascites (drain) muscle pain - necrotic tumor (resection)
What are the indications for radiation treatment in the treatment of cancer pain?
Headache - primary cerebral tumor, brain mets
Bone pain - pathological fracture, metastases
Pelvic pain - local tumor infiltration
Abdominal distention - ascites (drain)
muscle pain - necrotic tumor (resection)
chest pain - primary lung
What are the indications for chemotherapy in the treatment of cancer pain?
bone mets, brain mets, ascites, subacute obstruction, pancreatic pain, local tumor infiltration to chest or pelvis
For each indication, what is the most appropriate interventional pain procedure?
- Pancreatic Ca pain
- Pelvic Ca Pain
- Perineum pain due to pelvic tumors
- unilateral, neuropathic pain below C5 level
- vetrebral compression fracture
- celiac plexus block
- superior hypogastric plexus block
- Ganglion of Impar block
- cordotomy
- Vertebroplasty
Alcohol differs from phenol in many ways. List the differences in these categories:
- Physical characteristic:
- Concentration:
- Baricity
- Pain on injection
- MOA
- Duration
- alcohol - water soluble, phenol - not
- 50- 100%; 6-10% in gylcerol
- hypobaric; hyperbaric
- immediate burning; painless
- extracts phospholipid, cholesterol and cerebroside and precipitates mucoprotein and lioprotein; induces protein precipitation, loss of cellular fatty elements (myelin), affinity for vascular tissue
- longer; shorter and less profound
What are the indications to an intrathecal pump?
- responsive to systemic opioids but intolerable side effects
- resistant to high dose opioids
What are the contraindications to an intrathecal pump?
elevated ICP
infections near or at spine or generalized infections
suspected tumor mass at site
hemorrhagic diathesis
allergic reaction to epidural or intrathecal agents
expected problem in nursing care or device refills
When should intrathecal pump be internal or external and what are some complications of an intrathecal pump?
external if goal is focal analgesia and short life expectancy
internal if life expectancy >3months
Complications:
Meds related - nausea, urinary retention, pruritis
Procedure related - dural puncture headache, infection, nerve damage, pain
Device related - pump malfunction, infection
Name six neuropathic syndromes that are related to tumour burden?
plexopathy malignant painful radiculopathy painful cranial neuralgias (glossopharyngeal and trigeminal neuralgias) leptomeningeal metastases painful peripheral neuropathies paraneoplastic sensory neuropathy
Name seven visceral nociceptive syndromes present in cancer states.
chronic intestinal obstruction peritoneal carcinomatosis malignant perineal pain adrenal pain syndrome ureteric obstruction hepatic distension syndrome midline retroperitoneal syndrome
Tumor related bone pain syndromes
multifocal bone pain (metastatic invasion or focal invasion)
vertebral syndrome (A-A destruction and odontoid #, spinal cord compression pain)
pain syndromes related to the pelvis (pelvic and hip #)
base of skull metastases (olfactory groove syndrome, orbital syndrome, sella turcica syndrome, sphenoid sinus syndrome, cavernous sinus syndrome, Gasserion Ganglion syndrome, clivus syndrome, occipital condyle syndrome, cerebellopontine angle syndrome, jugular foramen syndrome)
What are six paraneoplastic pain syndromes?
- muscle cramps
- oncogenic osteomalacia
- hypertrophic pulmonary osteoarthropathy
- tumor-related gynecomastia
- paraneoplastic pemphigus
- paraneoplastic Raynaud’s phenomenon
Name 4 chemotherapy-related causes of pain
- CIPN
- Raynauds
- avascular necrosis of the hip
- vertebral compression #
Name 6 radiation-related causes of pain
- radiation induced brachial plexopathy
- chronic radiation myelopathy
- chronic radiation proctitis and enteritis
- lymphoedema pain
- burning perineum pain
- osteoradionecrosis
What are the three most common sites of metastases?
lung
liver
bone
pathological fractures are most common in _____ and ___ and cause fractures in what three sites?
myeloma, breast Ca
long bones, ribs and vertebral bodies
What are the main chemotherapy agents that result in CIPN?
- platinum analogues (cisplatin, carboplatin)
- taxanes (paclitaxel, docitaxel)
- vinca alkaloids (vincristine)
What are the common symptoms in CIPN?
stocking gloves sensory changes and pain motor weakness cranial nerve deficits autonomic deficits decreased or absent DTR (ankle primarily; first signs)
Medications used in CIPN?
Duloxetine (most evidence/studied)
Tests used for CIPN?
EMG/NCS
QST
Agents that have been used for prevention of CIPN?
alpha-lipoeic acid leukemia inhibitor factor lithium floinic acid amifostine IGF-1 nimodipine glutamate glutathione pyridoxine calcium-magnesium solution
EAPC guidelines for opioid use in cancer are:
- use morphine as first choice for treatment of cancer pain
- use oral route using both IR and LA formulations
- for titration is starting with morphine IR q4h and BT q1h and then regular dose adjusted from there
Major neurological side effects of opioid treatment
- sedation
- myoclonus
- hyperalgesia
- hyperexcitability
- delirium
- muscle rigidity
- headaches
- hallucinations
Guidelines for medication choice in intrathecal pumps?
1st line - morphine
2nd line - alternative opioid (HM) or morphine + clonidine/bupivicaine
3rd line - fentanyl, sufentanil, fentanyl + BUP/clonidine
4th line - category one- meperidine, methadone, ROP or neostigmine; category two - baclofen; category three - tetracaine, midazolam, NMDAR antagonists
Major cardiopulmonary side effects of opioid treatment
resp depression non-cardiogenic pulmonary edema bradycardia hypotension cardiac dysrthymias
Major GI side effects of opioid treatment
nausea/vomiting constipation xerostomia GERD common bile duct obstruction
Major urological side effects of opioid treatment
AKI
urinary retention
peripheral edema
Major endocrine side effects of opioid treatment
hypogonadism/sexual dysfunction
osteoporosis
Major dermatological side effects of opioid treatment
pruritis
diaphoresis
Major immunological side effects of opioid treatment
immune suppression
How are SC tumours classified?
Extradural
• Usually Metastatic – from lungs, breast, kidney, prostate
• Often arise in VB
• Can cause SC compression either via epidural growth
o extrinsic SC compression
o Cauda equina compression
o intradural invasion (less frequent)
Intradural • Extra-medullary (Tumor arise from w/in dura, but outside actual SC) o Usually benign o Meningiomas, Schwannomas (nerve sheath tumours) • Intra-medullary o Arise from SC itself o Primary intra-medullary tumours Ependymomas Astrocytomas o Mets Increasing frequency
