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

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

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

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." Cancer 118(8 Suppl):

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." Cancer 118(8 Suppl):

12. Breast Cancer Treatment Sequelae
The Pulling Through Study (longitudinal observational cohort study) provides data on prevalence of adverse effects in breast cancer survivors followed over 6 years. Followed 287 Australian women prospectively diagnosed with unilateral invasive breast cancer for median 6.6 years and prospectively assessed for treatment related complications at 6, 12, 18 months and 6 years.
Average age 55 yo, one-third had partial or full mastectomy, 2/3rd had lumpectomy, >75% had 5 or more LN removed, 75% XRT, 40% chemotherapy
Clinical assessment and/or completion of a self-administered questionanaire; some consented to questionnaire-only.
Self-report Functional Assessment of Cancer Therapy, breast+4 (FACT-B+4), self-report upper body function (Disability of the Arm, Shoulder and Hand (DASH scale).
BIS – bioelectrical impedance (impedance of the extracellular fluid for each arm was estimated); arm circumference – 1st and 5th metacarpal, wrist – distal edge of styloid process, then every 10cm along each arm up to 40cm, adding 6 measurements; difference >5cm = lymphedema
Proportion of survivors who maintained 1 or more adverse treatment effects remains stable over 6 years
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 ;118(8 Suppl):

13. Upper Extremity Pain in Breast Cancer Frequency of Current Self-Reported Symptoms by Year
Shoulder Stiffness
Arm Swelling
Arm Numbness
Arm Pain/Ache
yrs.
16.3
20.4
61.2
38.8
yrs.
20.7
24.6
65.9
44.9
yrs.
21.8
28.3
54.2
42.5
>4.0 yrs.
22.9
28.8
55.9
44.1
Questionnaire sent to Australian women with breast cancer >6 months ago; 809 women completed the survey
McCredie, et al. The Breast. 2001;10:

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
Scar tissue/myofascial adhesions
Axillary web syndrome – axillary cording, tight fibrous cords in the axilla that can extend along the arm to the antecubital fossa and forearm; due to disruption of lymphatic vessels and veins; SLND 20%; ALND 40-70%
Mondor’s disease – sentinel node biopsy complication; thrombophlebitis of the subcutaneous veins commonly occurs below the breast on the anterolateral thoracoabdominal wall; thrombosis of lateral thoracic and/or thoraco-epigastric veins; firm and tender cord of tissue traversing the upper abdomen into the lowr part of the breast, usually self-limited, resolveing 2-8wks
Radiation fibrosis syndrome

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):

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
Axillary web syndrome – axillary cording, tight fibrous cords in the axilla that can extend along the arm to the antecubital fossa and forearm; due to disruption of lymphatic vessels and veins; SLND 20%; ALND 40-70%
Mondor’s disease – sentinel node biopsy complication; thrombophlebitis of the subcutaneous veins commonly occurs below the breast on the anterolateral thoracoabdominal wall; thrombosis of lateral thoracic and/or thoraco-epigastric veins; firm and tender cord of tissue traversing the upper abdomen into the lowr part of the breast, usually self-limited, resolveing 2-8wks
Radiation fibrosis syndrome

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):
Intercostobrachial nerve is the lateral cutaneoius nerve of the 2nd thoracic root; provides sensation to the medial and posterior portion of the arm, axilla and lateral portion of the cheset wall; frequently affected by ALND

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
Intercostobrachial nerve is the lateral cutaneoius nerve of the 2nd thoracic root; provides sensation to the medial and posterior portion of the arm, axilla and lateral portion of the cheset wall; frequently affected by ALND

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
Latissimus dorsi

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):

25. Post-mastectomy syndrome Psychosocial 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 Manag 4(6):

26. Post-mastectomy syndrome Impact 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):
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