Post-mastectomy Syndrome:Identification

Katarzyna Ibanez, MD Assistant Attending PhysiatristMemorial Sloan-Kettering Cancer Center

Disclosures:

None

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

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 2015www.cancer.org

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 2015www.cancer.org

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 2015www.cancer.org

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

Upper body morbidity after breast cancerNeuromuscular

Cervical radiculopathy

Brachial plexopathy

Polyneuropathy

Mononeuropathies

Post-mastectomy syndrome

Intercostobrachial neuralgia

Complex Regional Pain Syndrome

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

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): 2237-2249.

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): 2237-2249.

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.

Upper Extremity Pain in Breast CancerFrequency of Current Self-Reported Symptoms by Year Shoulder

StiffnessArm Swelling Arm

NumbnessArm Pain/Ache

1.0-1.9 yrs. 16.3 20.4 61.2 38.8

2.0-2.9 yrs. 20.7 24.6 65.9 44.9

3.0-3.9 yrs. 21.8 28.3 54.2 42.5

>4.0 yrs. 22.9 28.8 55.9 44.1

McCredie, et al. The Breast. 2001;10:515-22.

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

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

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

Pain following mastectomy and breast reconstruction

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

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

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

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.

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

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

Post-mastectomy SyndromeRisk 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..

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 Manag 4(6): 445-459.

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.

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