1、TREATING PAIN AFTER SURGERYAndrea V.Barrio,MD,FACSAttending Breast SurgeonAssociate Program Director,Breast Fellowship ProgramThe Bryn Mawr HospitalINTRODUCTION Breast cancer most common cancer among women ACS estimates 232,340 new cases in 2013 Second most common cause death 39,620 deaths in 2013Tr
2、ends in 5Yr.survivalBREAST1975-19771984-19861996-2004CANCER75%79%89%www.cancer.orgPain after surgerySCOPE OF THE PROBLEM Estimated 2.9 million breast cancer survivors 2012 Persistent postsurgical pain demonstrated in 25-50%of patients undergoing breast cancer surgeryPain after surgery:IntroductionKe
3、hlet H,Lancet,2006OVERVIEW Anatomy Presentation of breast cancer Common surgical procedures for breast cancer Causes of acute post-surgical pain Causes of post-surgical sensory disturbances Lymphedema TreatmentPain after surgeryBREAST AND AXILLARY ANATOMYBREAST ANATOMY Female breast Lobules(milk-pro
4、ducing glands)Ducts(tubes carry milk from lobules to nipple)Stroma(fatty tissue and connective tissue surrounding ducts and lobules)Pain after surgeryTHE LYMPHATIC SYSTEM Part of bodys defense system Most lymphatic vessels in the breast connect to lymph nodes under the arm(axillary nodes)Some connec
5、t to lymph nodes inside the chest(internal mammary nodes)and some to those above the collar bone(supraclavicular nodes)Pain after surgeryPain after surgery:AnatomyPain after surgery:AnatomyHOW DO BREAST CANCERS PRESENT?BREAST CANCER PRESENTATION Imaging abnormality Mass Calcifications Architectural
6、distortion Palpable lump Skin changes Changes in nipple Rash Nipple dischargePain after surgeryBREAST CANCER PRESENTATION Imaging abnormality Mass Calcifications Architectural distortion Palpable lump Skin changes Changes in nipple Rash Nipple dischargePain after surgeryBREAST CANCER PRESENTATION Im
7、aging abnormality Mass Calcifications Architectural distortion Palpable lump Skin changes Changes in nipple Rash Nipple dischargePain after surgeryDiagnosis usually made with image-guided biopsyIMAGE-GUIDED BREAST BIOPSY Minimally invasive biopsy standard of care for initial diagnosis of imaging abn
8、ormalities Hematoma after biopsy can often cause significant discomfort/painPain after surgeryCAN I DECREASE MY CHANCES OF HAVING A POST-BIOPSY HEMATOMA?Often unavoidable Avoid blood thinners Coumadin Anti-platelets Aspirin?Vitamin E Fish oilPain after surgerySURGICAL PROCEDURES OF THE BREASTLUMPECT
9、OMY Incision is made on the breast Removes the breast cancer with a rim of normal tissuePain after surgeryRADIATION THERAPY Treatment with high energy rays that destroy cancer cells The treatment is used to kill cancer cells that remain in the breast Treatment with lumpectomy is almost always follow
10、ed by radiation therapy Radiation therapy decreases the likelihood of the cancer coming back in the breast by more than 50%Pain after surgeryMASTECTOMY Removal of the entire breast including the nipple and areola,leaving the pectoralis major intact With a mastectomy,radiation is usually not necessar
11、yPain after surgerySURGICAL PROCEDURES OF THE AXILLAAXILLARY LYMPH NODE DISSECTION An important part of staging breast cancer is determining if the lymph nodes under the arm are involved with cancer 10 40 lymph nodes are removed during a standard ALND Was once standard of care for breast cancer pati
12、entsPain after surgerySENTINEL LYMPH NODE BIOPSY Sentinel lymph node is the first lymph node to receive drainage from the breast or a tumor in the breast Injection of radiotracer+/-blue dye into the skin A gamma probe used to detect radioactivity in the axilla Only nodes that are hot and/or blue are
13、 removedPain after surgeryCAUSES OF ACUTE POST-SURGICAL PAINCELLULITIS/ABSCESS Post-operative infection rare,but can occur in breast or axilla If superficial,can treat with antibiotics If deeper infection suspected,may require incision and drainage of infected fluidPain after surgeryMONDORS DISEASE
14、Thrombosis of superficial vein Presents as a firm tender cord of tissue usually from upper abdomen to lower part of breast May occur after breast surgery Self-limited(resolves within 2-8 weeks)Treatment:Heat Anti-inflammatory medicationPain after surgerySEROMA Collection of fluid in surgical cavity
15、Normal part of wound healing Seroma may become tense and painful,particularly in axilla Treatment:Simple aspiration Repeated as necessaryPain after surgeryAXILLARY WEB SYNDROME Can be seen after any axillary surgery Presents as a series of tender,cord-like structures that are visible and palpable be
16、neath axillary skin Cords can extend down the arm,into forearmPain after surgeryAXILLARY WEB SYNDROME“Cording”due to disruption of lymphatic vessels during axillary surgery Incidence:20%after sentinel node biopsy 44%-72%after axillary node dissection Develops in early post-operative period Limits ra
17、nge of motion Treatment:PHYSICAL THERAPY to improve symptoms and shorten coursePain after surgerySHOULDER ABDUCTION MORBIDITY After axillary surgery,range of motion in shoulder may be significantly limited May be due to:Pain Scar tissue Axillary web syndrome Study demonstrated shoulder deficits 1 we
18、ek after surgery:41%after SLN biopsy 75%after ALND Symptoms were significantly improved 6 months after surgeryPain after surgeryAshikaga T,JSO,2010CAUSES OF POST-SURGICAL SENSORY DISTURBANCESBRACHIAL PLEXOPATHY Usually related to operative positioning Involves paresis of arm with sensory changes dis
19、tinct from minor sensory disturbances caused by injury to intercostobrachial nerve Prevention:Appropriate positioning including avoiding hyperextension of the arm Treatment:Physical therapyPain after surgeryNUMBNESS At incision site after lumpectomy or lymph node biopsy Of skin after mastectomy Inne
20、r arm after lymph node biopsy Intercostobrachial nerve often sacrificed during axillary dissection Even if preserved,may be stretched or injuredPain after surgeryNUMBNESS If nerve is sacrificed:Numbness under arm remains,but symptoms become significantly less distressing If nerve is simply stretched
21、:Normal sensation to the inner arm will return,but may take several monthsPain after surgeryPHANTOM BREAST PAIN Most common after mastectomy Johns Hopkins study reported 39%women had phantom sensations after mastectomy Incidence was similar with or without reconstruction During mastectomy,small nerv
22、es between breast and skin are cut Phantom sensations may be related to altered connection between the cut nerve and the brainPain after surgeryPHANTOM BREAST PAIN Common sensations reported:Pain and discomfort Itching Pins and needles Tingling Pressure Burning Throbbing Treatment:Exercise or“breast
23、”massage may help Pain medication for severe casesPain after surgery18 SENSATIONS AFTER BREAST CANCER SURGERY 187 patients with breast cancer completed questionnaire at 3,6,12,24 and 60 months after surgery 141 lumpectomy 46 mastectomy All had axillary surgery 133 sentinel node biopsy 54 axillary ly
24、mph node dissectionPain after surgeryBaron R,ASO,200618 SENSATIONS AFTER BREAST CANCER SURGERY Tender Sore Pull Ace Painful Twinge Tight Stiff Prick Throb Shoot Tingle Numb Burn Hard Sharp Nag PenetratePain after surgeryBaron R,ASO,200618 SENSATIONS AFTER BREAST CANCER SURGERY Most prevalent sensati
25、ons at baseline=tenderness Sensations less prevalent and less severe after sentinel node biopsy compared to axillary dissection Some sensations were prevalent,even at 5 years Tenderness and twinges after SLN biopsy Tightness and numbness after ALNDPain after surgeryBaron R,ASO,200618 SENSATIONS AFTE
26、R BREAST CANCER SURGERY Study provides valuable important information regarding what is to be normal and expected part of healing process Most sensations observed,even if prevalent,were not severe or distressingPain after surgeryBaron R,ASO,2006LYMPHEDEMA Potential cause of post-surgical pain Limb s
27、welling occurs as a result of protein rich fluid accumulating in the soft tissues Additional fluid build-up in arm can cause tingling,aching and heaviness Incidence 3-16%of women undergoing axillary surgeryPain after surgeryRISK FACTORS FOR LYMPHEDEMA Many retrospective studies evaluating associatio
28、n between risk factors and lymphedema1 Axillary lymph node dissection Mastectomy Obesity Radiation Infection Ipsilateral upper extremity injury Recent study reported that sauna use was only lifestyle risk factor associated with lymphedema1McLaughlin SA,Oncology,2012Showalter S,ASO,2013Pain after sur
29、geryTREATMENT/TIPS TO REDUCE SYMPTOMSPOST-OPERATIVE EXERCISE Early post-operative exercise most important In a review of 10 studies,introduction of upper extremity exercise as early as post-operative day 1 after axillary surgery showed clear benefit over delayed(day 5-7)for shoulder range of motion
30、Structured exercise programs with a physical therapist significantly improve post-operative range of motion and shoulder dysfunctionPain after surgeryMcNeely M,Cochrane review,2010PHYSICAL THERAPYPain after surgeryPHYSICAL THERAPYPain after surgeryPROSPECTIVE MODEL Pre-operative rehabilitation visit
31、 Establish baseline measurements including range of motion,pain,strength and upper extremity volume Early post-operative rehabilitation visit Address pain,decreased range of motion,axillary web syndrome,weakness Determine need for ongoing rehabilitation therapy Ongoing surveillance Recognizing patie
32、nts may need re-evaluation during additional reconstructive surgery,radiation or other therapiesPain after surgeryMcNeely M,Cancer,2012LYMPHEDEMA SURVEILLANCE/TREATMENT Surveillance Report any symptoms to surgeon or medical oncologist Immediate therapy can decrease symptoms TreatmentPhysical/Occupational therapyManual lymphatic drainageCompression garmentPain after surgeryALTERNATIVE THERAPIES Acupuncture/acupressure Most clinically common use of acupuncture is for treatment of pain Only a few studies to support findings Relaxation training Hypnosis YogaPain after surgery
