A Simple Intervention for Long-Term Relief of Chronic - - PowerPoint PPT Presentation

A Simple Intervention for Long-Term Relief of Chronic Post-Mastectomy Pain

Dr Holly Keane

Breast and General Surgeon Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne Australia Breast Surgery Research Fellow, University California, San Francisco, USA

Background

• Post-mastectomy pain syndrome (PMPS) is reported

to affect 25-60% of women after breast cancer surgery (Larsson, 2017)

• PMPS is thought to be a type of neuropathic pain or

complex chronic pain state, which is typically associated with nerve fiber injury

• Despite its prevalence, PMPS is infrequently

recognized (Swarm, 2013)

Background

• Potential cause of PMPS
• neuropathic pain condition
• damage to the T4 and T5 peripheral nerves of the chest wall

during surgery

• resulting in hypersensitivity and neuroma formation
• Clinically, this manifests as a syndrome with

persistent and often debilitating pain (Rajput, 2012)

• Diagnosed by identifying “trigger points”
• reproducible exquisite pain upon palpation

Path of the cutaneous branches of T4 and T5 nerves as they exit the chest wall

Study Design

• An observational cohort study of women with PMPS
• Breast surgery practice at the University of California

San Francisco Breast Care Center from August 2010 through March 2018.

• Women undergoing breast surgery presenting with:
• The clinical diagnosis of PMPS
• Point tenderness “trigger point” on infra mammary fold

Trigger point locations

Methods: Intervention

• Trigger point injections with:
• 2ml of 1:1 mixture
• 0.5% bupivacaine
• 4 mg/mL dexamethasone
• Skin marked at location trigger point
• 30G needle to deposit mixture into perineural space

Methods: Assessment

• Number of trigger points & injection locations
• documented prospectively and verified by chart review
• Patients assessed with regards to the effectiveness of

the trigger point injection:

• Physical examination immediately (1-3 minutes) after the

injection

• Long-term assessment with a telephone interview

conducted at least 3 months after the intervention

• Persistent or recurrent pain were offered a follow-up

appointment for repeat injections

Methods: Descriptive Statistics

• Electronic medical record (Apex Systems EHR),

Department of Surgery, UCSF

• Demographics
• Type of surgery
• Adjuvant radiotherapy?
• Surgical complications
• Duration pain
• Location of trigger points
• Number of injections required
• Univariate and bivariate analyses were conducted using

Stata 12 (College Station, TX)

Results

Local treatment characteristics Overall % Type of breast surgery lumpectomy reduction +/-lumpectomy mastectomy 6.56% 26.2% 67.2% Type of axillary surgery none sentinel node biopsy axillary node dissection 31.2% 42.6% 26.2% Adjuvant Radiotherapy 34.4% Descriptive Characteristics Overall % Age at 1st injection (range in years) 52 (30-92) Breast operations prior to injection 2.2 (1-8 ) Duration of pain (months, range) 22.5 (0.25-144 ) Trigger points per breast (range) 1.46 (1-4) Injections performed 1.49 (1-3) Duration of pain relief (months, range) 34.5 (3-88) % surgical complications 26.2% Surgical Complication severity Minor Major 56.3% 43.8%

• 91 trigger points
• 53 women
• majority mastectomy
• majority concurrent axillary

surgery

• long term relief* 92.3%
• 2nd injection

25.3%

Overall Outcomes per Trigger Point Injection

Conclusions

• Perineural infiltration with bupivacaine and

dexamethasone is a safe, simple, and effective treatment

• ption for PMPS with an associated trigger point.
• Our data suggest this significant problem can easily be

resolved in an outpatient setting.

• All breast specialists should inquire about the presence of

symptoms consistent with PMPS and understand the value of intervention to eliminate neuropathic pain.

• This technique should be added to the armamentarium of

all surgeons who perform breast surgery

References

• 1. The Post‐mastectomy Pain Syndrome—A Systematic Review of the Treatment Modalities - Larsson - 2017 - The Breast Journal - Wiley Online
• Library. https://onlinelibrary.wiley.com/doi/full/10.1111/tbj.12739.
• 2. Persistent Pain After Breast Cancer Treatment: A Critical Review of Risk Factors and Strategies for Prevention - ScienceDirect.

https://www.sciencedirect.com/science/article/pii/S1526590010008576?via%3Dihub.

• 3. Survey on recognition of post-mastectomy pain syndrome by breast specialist physician and present status of treatment in Japan | SpringerLink.

https://link.springer.com/article/10.1007%2Fs12282-012-0376-8.

• 4. Swarm RA, Abernethy AP, Anghelescu DL, et al. Adult Cancer Pain. J Natl Compr Cancer Netw JNCCN. 2013;11(8):992-1022.
• 5. Meijuan Y, Zhiyou P, Yuwen T, Ying F, Xinzhong C. A Retrospective Study of Postmastectomy Pain Syndrome: Incidence, Characteristics, Risk

Factors, and Influence on Quality of Life. Sci World J. 2013;2013. doi:10.1155/2013/159732

• 6. Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. The Lancet. 2006;367(9522):1618-1625. doi:10.1016/S0140-

6736(06)68700-X

• 7. Rajput K, Reddy S, Shankar H. Painful Neuromas. Clin J Pain. 2012;28(7):639. doi:10.1097/AJP.0b013e31823d30a2
• 8. Bridges D, Thompson SWN, Rice ASC. Mechanisms of neuropathic pain. Br J Anaesth. 2001;87(1):12-26. doi:10.1093/bja/87.1.12
• 9. Dindo D, Demartines N, Clavien P-A. Classification of Surgical Complications. Ann Surg. 2004;240(2):205-213.

doi:10.1097/01.sla.0000133083.54934.ae

• 10. Overview of the treatment of chronic non-cancer pain - UpToDate.
• 11. Jung BF, Ahrendt GM, Oaklander AL, Dworkin RH. Neuropathic pain following breast cancer surgery: proposed classification and research update.
• PAIN. 2003;104(1):1. doi:10.1016/S0304-3959(03)00241-0
• 12. Ueda H. Peripheral mechanisms of neuropathic pain – involvement of lysophosphatidic acid receptor-mediated demyelination. Mol Pain.

2008;4:11. doi:10.1186/1744-8069-4-11

• 13. Yoshimura M, Yonehara N. Alteration in sensitivity of ionotropic glutamate receptors and tachykinin receptors in spinal cord contribute to

development and maintenance of nerve injury-evoked neuropathic pain. Neurosci Res. 2006;56(1):21-28. doi:10.1016/j.neures.2006.04.015

• 14. Scholz J, Woolf CJ. Can we conquer pain? Nat Neurosci. 2002;5(11s):1062-1067. doi:10.1038/nn942