Cancer Pain Syndromes Flashcards

Question

Acute pain with chemotherapy toxicity: Intrathecal methotrexate

Answer 1

- Intrathecal methotrexate used for leukemia or leptomeningeal mets - Produces acute meningitic syndrome in 5-50% (HA is a prominent symptom), associated with nausea, vomiting, nuchal rigidity, fever, irritability, and lethargy - Symptoms begin hours after treatment and persist for several days Increased risk: - Multiple intrathecal injections - Treatment for leptomeningeal mets Tends not to recur with subsequent injections

Answer 2

- Systemic administration of L-asparaginase for acute lymphoblastic leukemia may cause a thrombosis of cerebral veins or dural sinuses (1-2% of patients) - HA is most common initial symptom, also seizures, hemiparesis, delirium, vomiting, or cranial nerve palsies - Diagnosis is with MRI (likely MRA?)

Answer 3

- Trans-retinoic acid therapy is used in the treatment of acute promyelocytic leukemia (APML) - May cause severe headache (pseudotumour cerebri induced by hypervitaminosis A) - May also produce a syndrome of diffuse bone pain (may be due to marrow expansion). Pain is generalised, of variable intensity, and associated with transient neutrophilia

Answer 4

Paclitaxel - Diffuse arthralgias and myalgias in 10-20% of patients - Related to individual doses, while cumulative dose/infusion duration has a less clear relationship Presentation: - Diffuse pain in joints and muscle 1-2 days after the infusion, lasting for median of 4-5 days - Pain commonly located in back, hips, shoulders, thighs, legs, feet - Exacerbated by weight bearing, walking, or tactile contact May be prevented by steroids

Answer 5

- Patients receiving 5-FU may develop ischemic chest pain - Risk is felt to range between 2-20%, risk higher with continuous infusion than with bolus therapy, and risk is higher in those with pre existing CAD - Likely due to coronary vasospasm - Similar reports with capecitabine (5-FU prodrug)

Answer 6

Hand food syndrome (aka palmar planter erythrodysesthesia) Associated with: - 5-FU continuous infusion - Capecitabine - Liposomal doxorubicin - Paclitaxel - Sorafenib and sunitinib - Everolimus Presentation: - Tingling or burning sensation in the palms and soles, followed by development of an erythematous rash Management - Discontinue therapy or dose reduce - Treatment with pyridoxine for resolution of the lesions

Answer 7

- Painful gynecomastia can occur as a delayed complication of chemotherapy - Testicular cancer is the most common underlying cancer, but others may be associated as well - May also be seen with anti-androgen therapies for prostate cancer (most commonly associated with bicalutamide) Presentation - Post-chemo, typically develops after latency of 2-9 months - Resolves spontaneously within a few months (but may occasional persist)

Answer 8

Raynaud's or transient ischemia of the toes, some case reports of gangrene ``` Associated agents: - Bleomycin - Vinblastine - Cisplatin (combo of three used for testicular cancer) ```

Answer 9

- Associated with vinorelbine (7%) - Pain begins within a few minutes of infusion, moderate to severe, and requires analgesia Prevention: Ketorolac may be helpful

Answer 10

- Initiation of LHRH agonist therapy for prostate cancer produces transient symptoms in 5-20% of patients - Short term, creates a transient increase in LH/testosterone, then suppresses levels Presentation: - Exacerbation of bone pain or urinary retention - Case reports of cord compression and sudden death - Occurs within first week of therapy, lasts 1-3 weeks in absence of an androgen antagonist Prevention: - Co-administration of an androgen antagonist

Answer 11

- Initiation of any hormonal therapy for metastatic breast cancer can be complicated by a sudden onset of diffuse MSK pain Presentation - Onset within hours to weeks of initiation of therapy - Erythema around cutaneous mets - Changes to LFTs - Hypercalcemia - Increased PET avidity Mechanism not understood, but may be predictive of later tumour response to hormonal therapy

Answer 12

- AIs may cause multifocal arthralgias in 10-20% of patients Presentation: - Early morning stiffness and hand/wrist pain - Variable intensity, may interfere with activity Management - Occasionally severe enough to justify discontinuation - NSAIDs often poorly effective - May be associated with osteoporosis - vit D and targeted therapies being investigated

Answer 13

- Essentially all patients treated with interferon experience acute syndrome Presentation - Fever - Chills - Myalgias - Arthralgias - Headache Onset is shortly after initial dosing, typically improves with continued administration Prevention: - Premedicate with acetaminophen

Answer 14

Infusion with IV bisphosphonates may be associated with multifocal bone pain and/or myalgia Occurs within 24 hours of infusion, may last up to 3 days Variable, may be severe and require analgesia Self-limiting

Answer 15

Typically from GCSF or Granulocyte-macrophage colony stimulating factor (GMCSF) Presentation - Mild to mod bone pain - Constitutional symptoms (fever, headache, myalgias) during administration - Pain intensity variable, may be severe Management - Co-administration with dex

Answer 16

- Incident pain during transport and positioning - Acute radiation toxicity (inflammation and ulceration of skin or mucous membranes) - Window specific

Answer 17

- Invariable at doses above 1000cGy - Severity of oral pain is variable, but may impact PO intake - May last several weeks post treatment

Answer 18

- Incidence as high as 50% in patients receiving abdominal/pelvic rads Presentation: - Small intestine - cramping, nausea, diarrhea - Proctocolitis - tenesmal pain, diarrhea, mucous discharge, bleeding Self-limited, typically resolves after completion but may slowly resolve over 2-6 months Acute enteritis increases risk of late-onset radiation enteritis

Answer 19

- Seen in breast CA patients after rads to the chest wall and adjacent nodal areas, as well as Hodgkin's lymphoma - Transient, self-limiting Presentations: - Paresthesias in brachial distribution - Pain and weakness (less common) Not predictive of delayed onset, progressive plexopathy

Answer 20

- Uncommon, may occur following rads to extra spinal tumours - Seen in Head and Neck cancers and with Hodgkin's Lymphoma Presentation: - Lhermitte's sign (shock like pains in the neck precipitated by neck flexion) - Pain may radiate down spine, into extremities - Onset weeks to months post rads, then resolves over 3-6 months

Answer 21

- Palliative rads to bony mets can lead to a pain flare in 30-40% immediately post rads - Occurs 1-2 days post rads, then typically resolves after 3-5 days - May be predictive of good analgesic response to rads Prevention: - Single 8mg dose of dex prior to rads (reduces severity and incidence)

Answer 22

- Higher incidence in cancer patients, especially in heme malignancies and those on immunosuppressive therapies Presentation - Continuous or lancinating pain - Typically resolves within 2 months, otherwise considered post-herpetic neuralgia (more likely in disseminated infection) - Dermatomal location of correlates with the site of malignancy

Answer 23

- Thrombosis is a frequent complication and cause of death in malignancy - Due to prothrombotic factors in cancer (tumour cells, products interacting with platelets/coagulation) - Highest association with bone, ovary, brain, and pancreas

Answer 24

Presentation - Pain (Variable, often a dull cramp or diffuse heaviness, worse with standing or walking) - Swelling - Palpable cord - Erythema - Warmth Rarely, may see ischemic DVT - tissue ischemia or frank gangrene (severe pain, extensive edema, cyanosis). IV thrombolytic may be most appropriate - consult heme, mortality rate is high.

Answer 25

Presentation - Edema - Dilated collateral circulation - Pain (typically in arm) Etiology - Central venous catheterisation - Extrinsic compression by tumour

Answer 26

- Typically due to external compression of the SVC by enlarged mediastinal LN - Associated with lung cancer and lymphoma most common Presentation: - Facial swelling - Dilated neck and chest collaterals - Chest pain - Headache - Mastalgia

Answer 27

- Associated with hypercoagulable states or extrenisic compression by adenopathy Presentation: - Acute abdominal pain - May be incidental finding Management: - Bowel rest - IVF - IV anticoagulation - May require lytic

Answer 28

- Common in cancer Presentation - Development of a palpable tender cord with erythema - US can rule out DVT - Trousseau's syndrome is migratory thrombophlebeitis (recurrent, migratory pattern and involvement of superficial veins, often in usual sites such as arm or chest) - sign of malignancy, especially gastric, pancreatic, and lung CA

Answer 29

Differential diagnosis: - Bony mets (often from lung, breast, prostate) - causes pain in 75% of patients - Osteoporotic fractures - Focal osteonecrosis (idiopathic or secondary to chemo) - Osteomalacia - Paraneoplastic osteomalacia (rare) Multifocal bone pain - Bony mets - Generalised pain due to replacement of the bone marrow (especially in heme malignancies - dx with MRI or PET, not seen on XR or bone scans) Vertebral syndromes - Bony mets or multilevel involvement

Answer 30

Atlantoaxial destruction and odontoid fracture Presentation: - Nuchal or occipital pain - Radiates over posterior aspect of the skull to the vertex - Exacerbated by movement of the neck (especially flexion) - May progress to secondary subluxation and cervical cord compression (early involvement of upper extremities, deficits slowly progress to involve sensory, motor, autonomic function)

Answer 31

C7-T1 Syndrome - Invasion of the C7 or T1 vertebrae can result in pain referred to interscapular region - Caution to not miss lesion if only getting XR of area caudal to C7/T1 - May be difficult to see on radiographs due to mediastinal shadows/overlying bone - get XR of cervical and thoracic spine if interscapular pain is present

Answer 32

T12-L1 (Thoracolumbar junction syndrome) - Referred pain to ipsilateral iliac crest or sacroiliac bone - Ensure spine is included in imaging as pelvic XRs can miss the source of the pain

Answer 33

Sacral syndrome Presentation: - Severe focal pain radiation to buttocks, perineum, or posterior thighs - Excerbated by sitting or laying, relieved by standing/walking - Destruction of the sacrum, and tumour may extend laterally to involve muscles rotating the hip - Can produce severe incident pain induced by hip motion or malignant pyriformis syndrome (buttock or posterior leg pain exacerbated by internal hip rotation)

Answer 34

Back pain and epidural compression - Pain typically first symptom, slowly progressive, and may preceded neuro symptoms for some time - Effective treatment is important to ensure complications and further deficits are prevented - Most important determinate of efficacy of treatment is degree of neuro impairment when therapy is initiated - MRI to diagnose, preferred modaility. CT is next best. Upper Motor neuron symptoms (spinal cord compression) - Pain excerbated by recumbency, cough, sneeze, strain - Lhermitte's sign - Spasticity - Hyperreflexia below lesion - Weakness (symmetric - typically develops to paralysis within 7 days!) - Numbness/parasthesias (symmetric, ascending, upper level of sensory loss may correspond to location of tumour) - Sphincter dysfunction (later) - Spinal tenderness to percussion Lower Motor neuron symptoms (Cauda equina) - Hypotonia - Areflexia or hyporeflexia - Weakness (symmetric) - Numbness/parasthesias (especially saddle anesthesia) - Sphincter dysfunction (later) - Fasciculations Consider cerebral mets if there are asymmetric UMN findings!

Answer 35

Sclerotic lesions/osteoblastic lesions - Typically more slow growing with sclerosis (bone forming) - Often seen in breast cancer, prostate CA, SCLC, Hodgkin Lymphoma - Elevated ALP is a marker of osteoblast activity

Answer 36

Lytic lesions/osteoclastic lesions - Typically more rapid with lysis (bone destructive) - Most common feature of multiple myeloma, breast cancer, renal cell, melanoma, NSCLC, thyroid cancer

Answer 37

Hip joint syndrome - Tumour involvement of the acetabulum or head of the femur - Produces localized hip pain aggravated by weight bearing and movement of the hip, may radiate to knee or medial thigh - Evaluate with CT or MRI Ddx: - Avascular necrosis - Radicular pain (L1) - Occult infections

Answer 38

Acrometastases - Mets in hands and feet (rare) - More often the larger bones in the feet (os calcis or talus) - Vague symptoms, may vague others (RA, osteomyelitis, etc.)

Answer 39

Hypertrophic Pulmonary osteoarthropathy (HPOA) - Paraneoplastic syndrome - Clubbing of the fingers - Periostitis of the long bones - Rheumatoid like polyarthritis - Most commonly associated with NSCLC, but may be associated with pulmonary mets from other sites Presentation: - pain, tenderness, and swelling in the knees, wrists and ankles - Onset typically subacute and may precede cancer dx by several months - Radiographical appearance Management: - May regress with anti tumour therapy - Bisphosphonates

Answer 40

Muscle cramps - Typically caused by an identifiable abnormality (neural, muscular, biochem) - E.g. peripheral neuropathy, nerve root/plexus pathology, polymyositis, hypomagnesemia

Answer 41

- Pain may arise from soft tissue sarcomas arising from fat, fibrous tissue, or skeletal muscle - Skeletal muscle mets are unusual, but may occur at sites of prior muscle trauma - Typically painful but may present with persistent ache

Answer 42

- HA is often the first presenting symptom of brain tumour or mets - Often associated with dizziness - Pain presumably preduced by traction to pain sensitive vascular/dural tissues - More pain with multiple mets and posterior fossa mets

Answer 43

Leptomeningeal mets: - Diffuse or multifocal involvement of the subarachnoid space by tumour - Incidence of 1-8% in systemic cancer - Acute lymphocytic leukemia and Non-Hodgkin's are often culprits - Breast adenoca and SCLC ca also common Presentation: - HA (Variable, may be associated with changes in mental status, N/V, tinnitus, or nuchal rigidity) - Cranial nerve palsies (diplopia, hearing loss, numbness, visual impairment) - Radicular pain in low back and buttocks - Less commonly - seizures, papilloedema, hemiparesis, ataxia, confusion Investigation: - Gad enhanced MRI - 90% sensitive (10% false negatives!) - CSF analysis - elevated protein, low gluc, lymphocytes, positive cytology (but may require repeated testing to confirm) Prognosis: - If untreated, progressive neurologic dysfunction and death in 4-6 weeks Treatment: - Rads - Steroids - Intrathecal chemo

Answer 44

Orbital mets - Progressive pain in the retro-orbital and supra orbital area of the affected eye - Blurred vision and diplopia Presentation - Proptosis - Chemosis - External opthalmoparesis - Ipsilateral papilloedema - Decreased sensation in the opthalmic division of the trigeminal nerve

Answer 45

Parasellar syndrome: - Unilateral supraorbital and frontal HA - May be associated with diplopia - May have opthalmoparesis or papilloedema - Visual field testing may show hemianopsia or quadrantinopsia

Answer 46

Middle cranial fossa syndrome: - Facial numbness - Paresthesias - Pain (usually referred to cheek or jaw, trigeminal branch distribution) - Pain is dull, continual ache, may be paroxysmal or lancinating - Hypoesthesia in trigeminal nerve, weakness in ipsilateral muscles of mastication

Answer 47

Jugular foramen syndrome - Hoarseness or dysphagia - Pain referred to the ipsilateral ear or mastoid region, may be referred to ipsilateral neck or shoulder - Ipsilateral Horner's syndrome (mioisis, ptosis, anhydrosis) - Paresis of the palate, vocal cord, SCM, or trapezius

Answer 48

Occipital condyle syndrome - Unilateral occipital pain worsened with neck flexion - Neck stiffness - Variable pain intensity, can be severe On exam: - Head tilt - Limited ROM in neck - Tenderness over occiputo-nuchal junction - Ipsilateral hypoglossal nerve paralysis and SCM weakness

Answer 49

Clivus syndrome - Vertex headache, often exacerbated by neck flexion - May also have CN VI-XII dysfunction and extend bilaterally

Answer 50

Sphenoid sinus mets - Bi frontal or retroorbital pain - May radiate to temporal regions - Nasal congestion and dipolopia - PE often normal, but unilateral or bilateral sixth nerve paresis can occur (impaired eye abduction)

Answer 51

Glossopharyngeal neuralgia - Reported in patients with leptomeningeal mets, jugular foramen syndrome, or head and neck cancer Presentation - Severe pain in the throat or neck, may radiate to the ear or mastoid region - May be worsened by swallowing - Pain may be associated with sudden orthostasis and syncope

Answer 52

Trigeminal neuralgia - Pain may be continual, paroxysmal, or lancinating - May be triggered by chewing, brushing teeth, speaking - May be induced by tumours in middle or posterior fossa or leptomeningeal mets - Any cancer patient developing trigeminal neuralgia should be investigated for mets

Answer 53

- Sensation of pain in the ear - may be primary or referred from cranial nerves - Causes: acoustic neuroma, mets to the temporal bone, infratemporal fossa - May also be referred from oropharyngeal/hypopharyngeal tumours

Answer 54

- May occur due to choroidal mets if accompanied by blurring vision - More commonly, mets to the bony orbit, rectus muscles, optic nerve, or caverbus sinus

Answer 55

- Migraine like headache, conscious disturbance, seizure, cortical vision loss with edema in the posterior regions of the brain on imaging - Posterior reversible encephalopathy syndrome - most commonly seen in Hodgkin's disease

Answer 56

Painful radiculopathy - May occur from any process that compresses, distorts, or inflames nerve roots - Important presentation of epidural tumours and leptomeningeal mets

Answer 57

- Neuralgia that persists four beyond four months in the same distribution of the original herpes zoster - Thoracic, cervical, trigeminal nerves most commonly affected - High prevalence in the cancer population - Pain may be burning, sharp, or stabbing and constant or intermittent, may also be accompanied by sensory deficits

Answer 58

Cervical plexopathy - Cervical plexus injury is most commonly due to tumour infiltration or treatment to neoplasms in the area - May also be due to direct invasion or tumour compression of the cervical plexus from mets of the cervical LN or primary head and neck cancer - Pain typically experienced in preauricular or postauricular regions, or anterior neck - May be referred to lateral aspect of the face, head, or ipsilateral shoulder - Can be associated with ipsilateral Horner's syndrome (miosis, ptosis, anhydrosis) or hemidiphragmatic paralysis CT or MRI of neck and C spine to diagnosis

Answer 59

Malignant brachial plexopathy - Most prevalent cause of brachial plexopathy - Most commonly seen in lymphoma, lung ca, or breast ca - Invading tumour arises from adjacent lymph nodes or lung Presentation - Pain typically occurs first, prior to neurologic signs or symptoms - More commonly involves C7, C8, T1 (reflected in pain distribution affecting elbow, medial forearm, fourth and fifth fingers) - Lower plexus (C7 - T1) = pain and paresthesias in shoulder, elbow, hand, 4th and 5th finger - Upper plexus (C5-C6) = pain in shoulder, biceps, elbow, hand, paresthesias - Pain typically aching, may also be constant or lancinating Diagnosis - MRI likely superior to CT - May require EMG - PET may help to differentiate tumour progression from radiation-related fibrosis, also note that patients with radiation-induced plexopathy typically have LESS pain Prognosis - High risk of epidural extension as the neoplasm grows medially and invades vertebrae or tracks along nerve roots - Watch for Horner's syndrome, panplexopathy, or vertebral damage on imaging

Answer 60

Radiation-induced brachial plexopathy - May be early-onset and transient or delayed onset and progressive Delayed onset progressive brachial plexopathy - May occur 6 months to 20 years post-rads, if the brachial plexus was included in the window - Pain is relatively uncommon and not severe if it occurs - Weakness and sensory changes, especially in the upper plexus - Associated lymphedema Diagnosis: - CT - EMG (Demyelination on motor nerve conduction studies with widespread myokymia)

Answer 61

Malignant Lumbosacral Plexopathy - Most commonly associated with colorectal, cervical, breast, sarcoma, and lymphoma - Typically direct invasion from intrapelvic neoplasm, 25% are from mets Presentation: - Pain is the first symptom - Aching, pressure like, or stabbing - Numbness, paresthesias, weakness weeks to months later - Common sights include leg weakness involving multiple myotomes, sensory loss crossing dermatomes, reflex asymmetry, focal tenderness, and leg edema Diagnosis: - CT or MRI from the L1 vertebral body through the sciatic notch - MRI likely more sensitive - If there is any concern for cord compression, ensuring the cord is adequately imaged (e.g. bilat symptoms, incontinence, paraspinal mass)

Answer 62

Radiation-induced Lumbosacral Plexopathy - Uncommon, may occur from 1-30 years after rads - Presents with progressive weakness and leg swelling, pain not typically a common feature - Weakness begins in L5-S1 segments, slowly progressive, may be bilateral - EMG may show myokymic discharge

Answer 63

Tumour related mononeuropathy - May occur from compression or infiltration of a nerve from tumour arising in an adjacent bony structure - Most common would be intercostal nerve injury from rib mets - Sciatica (tumour invasion of sciatic notch)

Answer 64

Paraneoplastic painful peripheral neuropathy - May be related to injury to the dorsal root ganglion or injury to peripheral nerves - May present as pain, paresthesias, sensory loss in the extremities, and severe sensory ataxia (associated with SCLC especially) - Typically develops before tumour is evidence - May also find coexisting autonomic, cerebellar, or cerebral abnormalities Diagnosis: - Anti-Hu antibodies

Answer 65

- Liver capsular pain secondary to tumour growth - Numerous sensitive structures in the region include the liver capsule, blood vessels, and biliary tract Presentation - Right subcostal pain - Referred pain to right neck or shoulder or in the right scapula - May result in overlying peritonitis which can result in a palpable or audible rub

Answer 66

Midline retroperitoneal syndrome - Occurs due to cancers involving the upper abdominal peritoneal structures - May result in injury to deep somatic structures of the posterior abdominal wall, distortion of pain sensitive connective tissue, vascular and ductal structures, local inflammation, and direct infiltration of the celiac plexus - Most commonly due to pancreatic cancer or retroperitoneal adenopathy Presentation: - Pain in the epigastrum or low thoracic region ot he back - Diffuse and poorly localised - Dull, boring in character - Worse with laying and improved by sitting

Answer 67

- Pain occurs due to smooth muscle contraction, mesenteric tension, and mural ischemia Presentation: - Continuous and colicky pain - Vomiting, anorexia, constipation

Answer 68

- Pain occurs due to peritoneal inflammation, mesenteric tethering, malignant adhesions, and ascites - Pain and abdominal distention

Answer 69

Causes of perineal pain: - Tumours of the colon or rectum, female reproductive tract, and distal genitourinary system - May be caused my microscopic perineural invasion by recurrent disease Presentation: - Constant and aching pain - Aggravated by sitting or standing - May be associated with tenesmus or bladder spasms

Answer 70

- Typically caused by tumour compression or infiltration within the pelvis, but less commonly can be associated with retroperitoneal adenopathy Presentation - Dull, chronic flank pain - Radiation into inguinal region or genitalia - May be complicated by pyelonephritis Diagnosis: - US, CT

Answer 71

Ovarian cancer pain - Moderate to severe chronic abdominopelvic pain (most common symptom of ovarian CA) - Low back or abdo pain

Answer 72

Lung cancer pain - May produce visceral pain syndrome (unilateral in most cases) - May be referred to the shoulder and lower chest - Early lung CA can generate ipsilateral facial pain (vagal afferent neurons affected)

Answer 73

- Tumours that secrete HCG (Testicular CA) may be associated with chronic breast tenderness - Approximately 10% of patients with testicular CA have gynecomastia or breast tenderness, higher levels of HCG correlate with gynecomastia

Answer 74

Paraneoplastic pemphigus - Rare mucocutaneous disorder associated with non-Hodgkin's lymphoma and chronic lymphocytic leukemia Presentation - Widespread shallow ulcers - Hemorrhagic crusting of the lips - Conjunctival bullae - Pulmonary lesions (less common)

Answer 75

- Reported with lung, ovarian, testicular, and melanoma

Answer 76

Toxic peripheral neuropathy - Common issue Presentation - Painful paresthesias - Stocking-glove sensory loss (axonopathy) - Weakness - Hyporeflexia - Autonomic dysfunction - Burning or lancinating pain, may be worsened with contact Agents - Vinca alkaloids (vincristine, vinblastine) - Cisplatin - Oxaliplatin - Paclitaxel

Answer 77

AVN - May occur spontaneously, or as a complication of continuous steroid tx - Also seen with high dose chemo with BMT - May be bilateral or unilateral Presentation - Most common in the femoral hip, causes pain in the hip, thigh or knee - In the humeral head, presents as pain in the shoulder, upper arm, or elbow - Local tenderness may be present over the joint - Pain worse with movement and relieved by rest Diagnosis - Pain precedes radiological changes by weeks to months - MRI is most sensitive Treatment - Analgesia - DC of steroids - Sometimes surgery or joint replacement

Answer 78

Chemo Plexopathy - Lumbosacral or brachial plexopathy may follow cis-platin infusion in tho the iliac artery - Occurs within 48 hours of infusion - Neurologic recovery/prognosis unclear

Answer 79

- Raynaud's observed in 20-30% of individuals with germ cell tumours treated with cisplatin/vinblastine/bleomycin

Answer 80

- MSK pain and stiffness | - Hand osteoarthritis, tendonitis, trigger finger, carpal tunnel

Answer 81

Osteonecrosis of the jaw - May occur after administration of bisphosphonages - Uncommon Presentation: - Unexpected development of necrotic bone in the oral cavity - Local pain, soft tissue swelling, or loss teeth - May be mistaken for more routine dental issues Prevention: - Dental examination and panoramic jaw radiograph before beginning bisphosphonate therapy - Ensure patients are informed of risks - Ensure regular good oral hygiene/regular dental assessment

Answer 82

- Warning regarding the risk of severe, sometimes incapacitating MSK pain in patients taking bisphosphonates - Onset is within days, months, or years - Some patients have relief after discontinuation, others do not - Risk factors unknown

Answer 83

Breast surgery pain syndromes Chronic neuropathic pain - Common complication, ,especially following axillary dissection - Risk and severity correlates to number of LN removed - Constricting and burning discomfort localised to the medial arm, axilla, and anterior chest wall - Onset may be immediate or months post-surgery - Variable natural history - More intense pain immediately post-op predicts worsened chronicity and complications Ddx: - Post mastectomy phantom breast pain - Neuroma pain - Post mastectomy frozen shoulder - Breast cellulitis - Axillary web syndrome

Answer 84

Post-radical neck dissection pain - Chronic neck and shoulder pain is common - Most often due to damage to the spinal accessory nerve (CN XI) - May also result from muscular imbalance following surgical excision of neck muscles Ensure imaging is performed to rule out recurrence or soft tissue infection

Answer 85

Prolonged post-thoracotomy pain - Most common pain pattern - Pain most profound around the surgical site - Pain is aching, tender, with numbness and burning - Due to trauma and compression to nerves, injury to chest muscles, fractured and compressed ribs - Typically resolves within 2 months, may persist up to 10 years Recurrent or Increasing post-thoracotomy pain - May be due to infection or disease recurrence - Requires evaluation with CT or MRI to rule out

Answer 86

- Risk for patients with post-thoracotomy pain or post-mastectomy pain - May result in independent, separate foci of pain - Ensure mobilization post-op to prevent

Answer 87

Phantom limb pain - Arises from am amputated limb - 60-80% of patients following limb amputation, but severe or persistent in only 5-10% of cases - More prevalent after tumour related than traumatic amputations, and post op chemo is an additional risk factor - Pre-op or post-op neural blockade may reduce incidence during the first year after amputation May also occur as phantom breast pain after mastectomy or phantom rectal pain after abdominoperineal resection

Answer 88

- Pain occurring at the site of a surgical scar several months to years following amputation - Most commonly due to development of neuroma at the site of a nerve transection Presentation: - Burning or lancinating dysesthesias - Worse with movement or pressure - Blocked by local anesthetic - Look for local inflammation (could indicate abscess formation)

Answer 89

- Uncommon, late complication of spinal cord irradiation - Onset typically 12-14 months post rads Presentation: - Partial, transverse myelopathy at the cervicothoracic level - Sensory symptoms, including pain, may precede motor and autonomic dysfunction - Pain is burning dysesthesia localised to the level of spinal cord damage or below Diagnosis: - MRI to rule out recurrence - MRI will show myelitis (high intensity T2 signals with gad enhancement) Prognosis: - Steady progression over months, followed by slow progression or stabilization

Answer 90

Chronic radiation enteritis and proctitis - Delayed complication in patients who under go abdominal or pelvic rads - Rectum and rectosigmoid most common Protocitis Presentation: - Proctitis (bloody diarrhea, tenesus, cramping pain) - Obstruction due to stricture formation - Fistulization to vagina or bladder Small bowel enteritis: - Colicky abdominal pain - Chronic nausea or malabsorption - On barium swallow, narrow tubular segment similar to Crohn's or ischemic colitis Diagnosis: - Endoscopy/biopsy

Answer 91

- Pelvic radiation may result in radiation cystitis - May result in temporary irritative voiding symptoms and asymptomatic hematuria - May be more severe - gross hematuria, non-functional bladder, persistent incontinence, FUND sx

Answer 92

- Common following breast cancer and axillary LN dissection Presentation: - Pain and tightness in the arm - May be complicated by secondary rotator cuff tendonitis due to internal derangement of tendon fibres If a patient has severe or increasing pain in a lymphedematous arm, consider tumour invasion of the brachial plexus

Answer 93

- Uncommon, delayed complication of pelvic radiotherapy - Onset 6-18 months post rads - Burning pain in the perianal area, may extend anteriorly to involve vagina or scrotum

Answer 94

- Late complication of radiotherapy | - Bone necrosis, producing focal pain

Answer 95

- PET may help to differentiate tumour progression from radiation-related fibrosis - Patients with radiation-induced plexopathy typically have LESS pain Tumour infiltration: - Pain progresses, more severe, and has a dysaesthetic quality - C7-T1 distribution (neck, shoulder, hand, 5th finger) - Mass on CT with tissue infiltration - High T2 signal intensity on MRI - Denervation on EMG, but no myokymia (ongoing depolarization) - Horner's may be present Radiation fibrosis: - Pain stabilises with onset of weakness - C5-C6 distribution (thumb, forearm) - Diffuse infiltration of tissue on CT - Low T2 signal intensity on MRI - Myokymia on EMG (ongoing depolarization) - No Horner's syndrome

Cancer Pain Syndromes Flashcards

(119 cards)