1. Pain syndromes in patients with cancer Prof. Miroslava Pjevic

3. Pain syndromes in patients with cancer ACUTE CANCER PAIN SYNDROMES CHRONIC CANCER PAIN SYNDROMES

4. ACUTE CANCER PAIN SYNDROMES Acute pain associated with diagnostic and therapeutic procedures Acute pain associated with anticancer therapies Acute pain associated with malignant disease indirectly (infection, myalgia, decubitus) Acute pain caused by tumor directly (intratumoral bleeding, pathological vertebral body fracture, acute bowel/ureteric obstruction)

5. ACUTE PAIN SYNDROMESACUTE PAIN SYNDROMES Cherny NI, Portenoy RK,1994. * (cont)

6. ACUTE PAIN SYNDROMESACUTE PAIN SYNDROMES Cherny NI, Portenoy RK,1994. * * (cont)

7. Painful mucositis (5 - 15%) Oral / pharyngeal Oesophageal Gastrointestinal (dyspepsia and diarrhoea) Myeloablative chemotherapy and radiotherapy that precede bone marrow transplantation (40-100%) Pain after 3-5 d, max 7-10 d Radiotherapy - head and neck (80-100%) strong pain at the end of 2 nd week, max 4 th week Persistent pain for about 2-3 weeks after radiotherapy Risk of infection (candida, herpes simplex) Incident BTP by taking food and swallowing

8. CHRONIC CANCER PAIN SYNDROMES Tumor related pain syndromes Pain syndromes of the bones Pain syndromes of the viscera Pain syndromes associated with neural tissue Pain syndromes associated with cancer therapy

9. CHRONICPAINSYNDROMESCHRONICPAINSYNDROMES Cherny NI, Portenoy RK,1994 *

10. CHRONICPAINSYNDROMESCHRONICPAINSYNDROMES (cont)

11. CHRONICPAINSYNDROMESCHRONICPAINSYNDROMES * Cherny NI, Portenoy RK,1994 (cont)

12. Bone pain Most common cause of chronic and progressive pain in the cancer population is tumor infiltration of bone primary (myeloma multiplex) Bone metastases/lesions Bone pain: dull or aching, deep, often constant, especially strong at night, well localised (focal), multifocal or generalized (multiple bony metastases) Early recognition (history, clinical finding, plain X-ray, “bone scan”, CT/ MRI)

13. Bone metastases Tumor infiltration of bone Lung ca 64% Breast ca 50-85% Prostate ca 60-85% Kidney ca 28-60% Urin. bladder ca 42% Gl thyroid. ca 28-60% Multiple sites or localised Vertebrae Pelvis Femur Ribs Base of skull Bone is the most common site of tumor metastases

14. Pain due to bone metastases More often painful (60-80%) Mechanical periosteum distortion (streching or pulling) Tumor compression or infiltration of adjacent soft tissues, vascular structures, nerves (neuropathic/mixed pain) Associated inflammation Associated muscle spasms Acute pain exacerbations (pathological fracture, EC of the spinal cord) Increased with activity- incident BTP Must be distinguished from other causes of bone pain Dificult and chalenging pain treatment

15. Vertebral syndromes The vertebre are the most common sites of bony metastases Thoracic (70%) Lumbosacral (20%) Cervical (10%) Multiple level involvment is common (85%) Early recognition of pain syndromes due to tumor invasion of vertebral bodies is essential Cauda equina syndrome is the most dificult complication of vertebral metastases

16. Clinical recognition of epidural extension Rapid progression of back pain in a crescendo pattern, persist at rest, worse at night Radicular pain is later sign (compression / infiltration of dorsal roots of spinal nerves), constant or lancinating, exacerbated by recumbency, cough, sneeze, relieved by standing, usually unilateral (cervical and l-s regions) and bilateral (thoracal region) Epidural compression (EC) of the spinal cord (cauda equina) after period of progressive pain

17. Epidural compression (EC) of the spinal cord (10%) Back PAIN = initial symptom ! Important to know and start EXTENSIVE evaluation and early diagnosis Cauda equina is the most serious complication of vertebral body metastases and is urgent state in oncology: Weakness Sensory loss Autonomic dysfunction and reflex abnormalities Paralysis (paraplegia, quadriplegia)

18. Pain syndromes of the bony pelvis and hip Common sites of bone metastases Weight–bearing function of these bones (ambulation - incident BTP) 1. Pelvis: ischiopubic, iliosacral, periacetabular 2. Proximal femur 3. Hip joint syndrome Hip pain localised or radiates to the knee or medial thigh, mixed pain if the lumbosacral plexus involved

19. Pain syndromes of the viscera Visceral tumor infiltration with or without pleura/peritoneum involved is the second most common cause of pain in patients with cancer (mixed nociceptive and neuropathic pain) Abdominal pain syndromes are more common: Hepatic distension syndrome (liver capsule, vessels and biliary tract) Midline retroperitoneal syndrome (coeliac plexus) Chronic intestinal obstruction (continuous and colicky pains) Peritoneal carcinomatosis Ureteric obstruction (tumor compression/infiltration within pelvis) Cancer perineal pain (tumors of the colon, rectum, female reproductive and genitourinary system), constant and aching pain, aggravated by sitting, standing

20. Pain syndromes associated with neural tissue Pain involving the peripheral nervous system is the third common cause of pain in cancer patients Neuropathic pain Pain is initial symptom and should be recognized

21. Pain syndromes associated with neural tissue Painful radiculopathy Painful plexopathy (cervical, brachial, lumbosacral) Painful mononeuropathy Painful peripheral neuropathies

22. Cervical plexopathy (C 1 -C 4 ) Head and neck primary tumor infiltration/compression of the cervical plexus Pain localised in pre/postauricular regions or anterior neck, may refer to the lateral aspect of the face or head and to the ipsilateral shoulder Strong, aching, burning, lancinating pain, often exacerbated by neck movement or swallowing

23. Brachial plexopathy tumor infiltration: Lung cancer (Pancoast) Breast cancer Lymphoma Upper plexopathy ( c 5 - C 6 ) (pain in shoulder, lateral arm, first and second fingers) Lower plexopathy (C 8 –T 1 ) (pain in elbow, medial forearm, fourth and fifth fingers) Radiation- induced brachial plexopathy Early-onset transient plexopathy Delayed-onset progressive plexopathy

24. Lumbosacral plexopathy Lumbar plexus (L 1 -L 4 ) and sacral plexus (L 4 -L 5, S 1 -S 3 ) tumor infiltration/compression (intrapelvic neoplasm: colorectal, cervical, lymphoma, sarcoma Upper plexopathy (30%) Colorectal tumor Pain in the lumbar back, lower abdomen, anterolateral thigh, inguinal region, buttock, leg Lower plexopathy (50%) Pelvic tumor: rectal, gynaecological, sarcoma Pain in buttock, perineum, posterolateral leg aspect, autonomic dysfunction (intestinal, bladder), leg oedema

25. In summary Early and right identification of cancer pain syndrome may help and simplify complex management in cancer patients