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Post-mastectomy Syndrome: Identification

Post-mastectomy Syndrome: Identification. Katarzyna Ibanez, MD Assistant Attending Physiatrist Memorial Sloan-Kettering Cancer Center. Disclosures:. None. Objectives:. Cancer s tatistics U pper body morbidity after breast cancer Define Post-mastectomy Syndrome

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Post-mastectomy Syndrome: Identification

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  1. Post-mastectomy Syndrome:Identification Katarzyna Ibanez, MD Assistant Attending Physiatrist Memorial Sloan-Kettering Cancer Center

  2. Disclosures: • None

  3. Objectives: • Cancer statistics • Upper body morbidity after breast cancer • Define Post-mastectomy Syndrome • Discuss epidemiology and etiology of symptoms • Differential diagnosis for Post-mastectomy Syndrome

  4. U.S. Cancer Statistics • 14.5 million with hx of cancer alive in 2014 • 1,658,370 new cancers expected to be diagnosed in 2015 • 589,430 expected to die of cancer in 2015 • Cancer death accounts for nearly 1 in 4 deaths • Direct medical costs for cancer treatment was $88.7 billion in 2011 Cancer Facts and Figures 2015 www.cancer.org

  5. U.S. Breast Cancer Statistics • 2.5 million breast cancer survivors • 1 in 8 women affected by breast cancer • 234,190 new cases expected to be diagnosed in 2015 • 231,840 women • 2,350 men • 40,730 deaths expected in 2015 • 40,290 women • 440 men Cancer Facts and Figures 2015 www.cancer.org

  6. U.S. Breast Cancer Statistics • Most commonly diagnosed cancer in women (except for skin cancer) • Second most common cause of cancer death in women (after lung cancer) • For all stages combined: • 5 year survival rate 89% • 10 year survival rate 83% • 15 year survival rate 78% Cancer Facts and Figures 2015 www.cancer.org

  7. Breast cancer treatment • Surgery • Lumpectomy or mastectomy • Sentinel lymph node biopsy or axillary lymph node dissection • Radiation • Hormonal therapy • Chemotherapy • ACT (Adriamycin, Cyclophosphamide, Taxol) • CMF (Cyclophosphamide, Methotrexate, Fluorouracil) Morbidity and functional impairments as a consequence of breast cancer treatment is common

  8. Upper body morbidity after breast cancer Neuromuscular Cervical radiculopathy Brachial plexopathy Polyneuropathy Mononeuropathies Post-mastectomy syndrome Intercostobrachial neuralgia Complex Regional Pain Syndrome

  9. Upper body morbidity after breast cancer Musculoskeletal Post-surgical pain Rotator cuff disease/Tendinosis/Adhesive Capsulitis Arthralgias and Myalgias Lymphovascular Lymphedema Axillary web syndrome Deep vein thrombosis and Post-thrombotic syndrome Integumentary Cellulitis Radiation dermatitis

  10. Upper body morbidity after breast cancer • Associated with alteration in use and function of the upper body • Has adverse physical, psychosocial and social ramifications which influence daily life and quality of life • 10-64% of women report upper body symptoms between 6 months and 3 years after treatment • Pain reported in 12 to 51% of patients • 20% develop lymphedema Hayes, S. C., et al. (2012). "Upper-body morbidity after breast cancer: incidence and evidence for evaluation, prevention, and management within a prospective surveillance model of care." Cancer118(8 Suppl): 2237-2249.

  11. Upper body morbidity after breast cancer Hayes, S. C., et al. (2012). "Upper-body morbidity after breast cancer: incidence and evidence for evaluation, prevention, and management within a prospective surveillance model of care." Cancer118(8 Suppl): 2237-2249.

  12. Breast Cancer Treatment Sequelae Schmitz KH, Speck RM, Rye SA, DiSipio T, Hayes SC. Prevalence of breast cancer treatment sequelae over 6 years of follow-up: the Pulling Through Study. Cancer. Apr 15 2012;118(8 Suppl):2217-2225.

  13. Upper Extremity Pain in Breast CancerFrequency of Current Self-Reported Symptoms by Year McCredie, et al. The Breast. 2001;10:515-22.

  14. Post-mastectomy syndrome - Definition • Chronic neuropathic pain condition that can occur following surgery to the breast • The exact mechanism is unknown but thought due to nerve damage, particularly those involving dissection of the axilla • Can start anytime after surgery but persists beyond normal healing time (~3months) • Pain neuropathic in character • Pain located in the chest wall, axilla, arm, or shoulder on the affected side

  15. Post-mastectomy syndrome - Continued • Symptoms vary depending on the type of surgery and the adjuvant treatment received as well as the individual patient • The extent of treatment consistently identified as a significant risk factor • Affects as many as 40% of patients

  16. Post-mastectomy Syndrome – Continued (2) • Symptoms include one or more of the following: • Pain (nociceptive and neuropathic, phantom, CRPS) • Sensory changes (paresthesias, dysesthesias, allodynia) • Spasms • Muscle atrophy • Muscle weakness • Capsular contracture • Limited range of motion • Edema/lymphedema – axilla, chest wall, breast, arm • Cording

  17. Pain following mastectomy and breast reconstruction • Incidence of pain • 31% with mastectomy alone • 49% with mastectomy and reconstruction • With implants – 53% • Without implants – 30% • Wallace MS, Wallace AM, Lee J, Dobke MK. Pain after breast surgery: a survey of 282 women. Pain. Aug 1996;66(2-3):195-205.

  18. Capsular contracture • Immune response to the foreign object • Tightly woven collagen fiber capsule tightnens and squeezes the implant • Painful and disfiguring • Baker capsular contracture scale • Grade I — the breast is normally soft; appears natural • Grade II — the breast is a little firm, appears normal • Grade III — the breast is firm and appears abnormal • Grade IV — the breast is hard, painful to the touch, and appears abnormal

  19. Axillary web syndrome Also known as cording • Tight fibrous cords in the axilla that can extend along the arm to the antecubital fossa and forearm • Believed to be due to disruption of lymphatic vessels and veins • Typically self-limited but may persist, cause pain and tightness

  20. Post-mastectomy syndrome • Associated signs may include: • Visible muscle spasms • Myokymia • Muscle atrophy • Muscle weakness • Radiation changes • Capsular contracture • Limited ROM • Edema/lymphedema • Cording • Tenderness • Disfigurement

  21. Possible etiologies of post-mastectomy pain • Axillary lymph node dissection • Sentinel lymph node dissection1 • Intercostobrachial nerve injury/entrapment • Axillary hematoma post surgery • Severe acute post-operative pain Miguel R, Kuhn AM, Shons AR, et al. The effect of sentinel node selective axillary lymphadenectomy on the incidence of postmastectomy pain syndrome. Cancer Control. Sep-Oct 2001;8(5):427-430.

  22. Possible etiologies of post-mastectomy pain • Phantom breast pain • May affect 23% of patients • Neuroma formation • Focal area of sensitivity commonly along borders of incision • Rule out local recurrence first • Incisional pain, scar tissue adherence

  23. Post-mastectomy syndrome – additional etiologies • Uncontrolled dystonic muscle spasms and hypertonicity of the chest wall musculature • Tissue ischemia and nerve compression • Pectoralis • Serratus anterior • Latissimusdorsi

  24. Post-mastectomy Syndrome Risk Factors • Younger age • Unmarried • Type/extent of surgery • Radiotherapy • Chemotherapy • Preoperative anxiety • Severe postoperative pain • Greater postoperative analgesic use Tasmuth T, von Smitten K, Hietanen P, Kataja M, Kalso E. Pain and other symptoms after different treatment modalities of breast cancer. Ann Oncol. May 1995;6(5):453-459..

  25. Post-mastectomy syndromePsychosocial factors • Additional risk factors for persistent pain after breast cancer surgery • Catastrophizing • Anxiety • Depression • Somatization • Sleep Quality Schreiber, K. L., et al. (2014). "Predicting, preventing and managing persistent pain after breast cancer surgery: the importance of psychosocial factors." Pain Manag4(6): 445-459.

  26. Post-mastectomy syndromeImpact on Psychosocial Functioning • Chronic pain affects lives • slightly: 50% • at least moderately: 25% • Limited activities due to pain: work, exercise, sleep, socializing, intimacy • Greater psychological or psychiatric morbidity, depression and anxiety Tasmuth T, von Smitten K, Hietanen P, Kataja M, Kalso E. Pain and other symptoms after different treatment modalities of breast cancer. Ann Oncol. May 1995;6(5):453-459. Stevens PE, Dibble SL, Miaskowski C. Prevalence, characteristics, and impact of postmastectomy pain syndrome: an investigation of women's experiences. Pain. Apr 1995;61(1):61-68. Jung BF, Ahrendt GM, Oaklander AL, Dworkin RH. Neuropathic pain following breast cancer surgery: proposed classification and research update. Pain. Jul 2003;104(1-2):1-13.

  27. Post-mastectomy Syndrome – Differential Diagnoses • Tumor recurrence • Paraneoplastic or chemotherapy induced neuropathy • Plexopathy • Rib fracture • Intraparenchymal lung pathology • Thoracic nerve root impingment • Intercostal neuralgia • Post-herpetic neuralgia

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