Somatic Pain

Question 1

Define somatic pain.

Answer 1

somatic pain is a subtype of nociceptive pain arising from bone and soft tissue

Question 2

What is the most common somatic pain syndrome?

Answer 2

Pain related to bone metastases is the most commonly encountered somatic pain syndrome.

Question 3

What two cancers are most often responsible for malignant bone disease?

Answer 3

Breast and Prostate Cancer. Occurs in 70% of patients.

Question 4

Name 3 cancers (other than breast and prostate) that also frequently metastasize to bone.

Answer 4

1) Thyroid
2) Lung
3) Kidney

Question 5

What cancer involves bone diffusely?

Answer 5

Multiple Myeloma

Question 6

Most people with bone mets will develop skeletal related events (SRE): Name 4 SRE that can occur.

Answer 6

1) Pathological fracture
2) Hypercalcemia
3) Pain
4) Spinal cord compression

Question 7

How does cancer induced (CIBP) bone pain typically present?

Answer 7

usually manifests as continuous localized, reproducible pain.

Question 8

What patient descriptor words often describe bone pain?

Name 2.

Answer 8

Aching
Gnawing

Question 9

Define breakthrough pain (BTP)

Answer 9

BTP: considered a transient exacerbation of pain, occurring spontaneously or related to a trigger, on a background of stable pain.

Question 10

How do osteolytic lesions appear on x-ray?

Answer 10

On plain radiographs, bone mets may appear as areas of absent density or absent trabecular structure, representing osteolytic lesions

Question 11

True or False

For bone mets, x-ray sensitivity is significantly lower compared to bone scan.

Answer 11

TRUE

The sensitivity for x-ray compared to bone scan is significantly lower.

Question 12

Bone scans can be falsely negative in the work up for multiple myeoloma. Why?

Answer 12

Minimal osteoblastic activity.

Question 13

What role does osteoprotegerin (OPG) play in the bone cycle.

Answer 13

OPG is a decoy receptor for excessive bone resorption.
It is PROTECTIVE against bone loss.
OPG regulates RANK ligand.
OPG is produced by osteoblasts.

Question 14

CIBP may arise from compromise of mechanical stability of bone.

1) Osteoclasts are responsible for bone ______

2) Osteoblasts are responsible for bone ______

Answer 14

1) Osteoclasts are responsible for bone RESORPTION

2) Osteoblasts are responsible for bone FORMATION

Question 15

How long do immediate release opioid formulations take to achieve meaningful pain relief?

Answer 15

30-40mins

Question 16

What receptor activator do osteoblasts normally express?

Answer 16

Osteoblasts normally express the receptor activator factor-kappa B ligand (RANKL),

Question 17

RANKL binds to what receptor?

Answer 17

The RANK receptor on osteoclast precursors

This promotes maturation and proliferation.

Question 18

This type of cancer does NOT show up on bone scans.

Answer 18

Multiple myeloma does NOT show any uptake on bone scan.

In multiple myeloma the osteoblastic response to bone destruction is negligible, therefore no uptake by bone scan.

Question 19

30-70% of normal bone mineral content must be lost before osteolytic vertebral lesions become apparent on ______.

Answer 19

XRAY

Question 20

1) How does an osteolytic lesion appear on x-ray?

2) How does an osteoblastic lesion appear on x-ray?

Answer 20

1) Areas of absent density or absent trabecular structure.

2) The bone becomes very dense (sclerotic).

Question 21

What are some non-cancer conditions that could show up on bone scan?

Name 4.

Answer 21

1) osteoarthritis
2) Infection
3) trauma
4) Paget’s disease

These non- cancer conditions would also have abnormal osteoblastic activity.

Bone scan lacks specificity.

Paget’s disease of bone is a chronic disease of the skeleton. Most often affects older people. The dIsease interrupts the bone remodeling process. New bone is made that is abnormally shaped, weak and brittle.

Question 22

____ has better contrast resolution for visualizing soft tissue and the spinal cord.

Answer 22

MRI.

Question 23

Name two adverse effects that can occur with NSAIDS.

Answer 23

1) Renal failure
2) Gastrointestinal ulceration

Risk of gastrointestinal toxicity is higher with increased age, previous peptic ulcer disease, comorbidities, use of multiple NSAIDS (including ASAs) and use in combination with corticosteroids.

Question 24

Regular administration of ____ has been shown to decrease SRE in breast ca and multiple myeloma.

Answer 24

Bisphosphonate

(zoledronic acid, pamidronate)

Bisphosphonates are synthetic analogues of pyrophosphate which bind to bone matrix and cause OSTEOCLAST APOPTOSIS, thereby reducing bone resorption.

Question 25

Denosumab is a human monoclonal antibody with high affinity and specificity for ______

Answer 25

RANKL.

By neutralizing RANKL, denosumab inhibits osteoclast formation, function and survival.

$$ compared to bisphosphonates.

Question 26

What non-pharmacological strategies can you suggest to a patient to manage bone pain?

Answer 26

OT (modification of environment)
PT (learning non weight bearing activities)

Question 27

Why are radiopharmaceutical radioactive agents laregly unhelpful to most palliative pateints?

Answer 27

Onset of analgesia is typically measures in months.

Question 28

What scoring system is the GOLD STANDARD to assess fracture risk?

Answer 28

Mirel’s scoring system

(system combines clinical and radiographic factors: associated pain, location, size, osteoblastic vs osteolytic lesions).

Question 29

Question 30

When would you consider a radiopharmaceutical?

Answer 30

multiple painful bone mets
good performance status
life expectancy measured in months

analgesic effect typically measured in months

Question 31

List 4 clinical situations where a fentanyl patch would NOT be good

Answer 31

1. Pain crisis
2. Opioid naive
3. Uncontrolled pain
4. Neuropathic or chronic pain

Question 32

Define pain

Answer 32

Unpleasant sensory and emotional experience associated with or resembling that associated with actual or potential tissue damage

Question 33

Define chronic pain

Answer 33

Pain which persists beyond the usual course of healing or is associated with chronic pathological illness which causes continuous pain or pain which recurs at intervals for months or years