Chronic pain following breast surgery - Do patients have to live with it ? Dr A. Lukas

20% 26% KI-AVL outpatient clinic Patientpopulation NKI-AVL outpatient clinic

KI-AVL outpatient clinic Patients with postmastectomy pain NKI-AVL outpatient clinic

PMPS - Pathofysiologie- 84% 74% 58% Stevens, Pain 1995, 61

Postmastectomy pain -Definition- deafferentation type pain syndrome immediately or as late as many months following surgery shock-like pain sensations overlying a more continuous aching and burning accompanied by dysesthesias, phantom sensations worsened by (arm) movement, lying on side natural history variable with subacute and chronic courses possible

Prevalence of postmastectomy pain

Postmastectomy pain -classification according to Jung et al., Pain 2003 Neuralgia intercostobrachial nerve (20-58%) Phantom breast pain (13-44%) Neuroma pain (23-49%) Other nerve injury pains

Postmastectomy pain -Risc factors- preoperative pain and unusual breast sensations postoperative complications surgical technique ( axillary dissection) subsequent chemotherapy / radiotherapy high intensity of acute postoperative pain young age psychological factors ( high levels of anxiety, depression, catastrophizing, somatization )

There are more reasons for pain following breast surgery !

sleep functioning sexuality fatigue pension / part-time work relationship problems reminds cancer anxiety Postmastectomy pain -factor-x-

Postmastectomy pain -Treatment - AuthorYearNTInterventionresult Vilholm levitiracetam 500->3000 mg/4wno pain relief Kalso venlafaxine 18,75- >75mg/4wrelief maximum pain Kalso amitriptylline 25->100 mg/d 50% pain relief at 50 mg NO PATIENT WANTED TO CONTINUE Watson capsaicine 0,075% topical /6w improvement of pain 3 PATIENTS CONTINUED

Lymphedema treatment

Physiotherapie ( feel & dare ! )

Psychological support bodyperception – perceive and accept changes Coping (limitation, mutilation) sexuality anxiety (recurrence) afraid of pain / harm fatigue

Analgesia and nerve function following pulsed radiofrequency for postmastectomy pain A. Lukas, H. van Tinteren, S. Linn, E. Rutgers, N. Aaronson, R. Perez

Pulsed radiofrequency treatment of neuropathic pain (PRF) Non-neurodestructive minimal invasive treatment option for neuropathic pain (if conservative treatment fails) Single intervention Possibly long-lasting effects if it does not help it does not harm

Analgesia and nerve function following pulsed radiofrequency for postmastectomy pain A. Lukas, H. van Tinteren,S. Linn, E. Rutgers, N. Aaronson, R. Perez Does PRF reduce the intensity of PMPS Possible mechanism of action PRF Has the type of nerve-lesion impact on the effect of PRF

Analgesia and nerve function following pulsed radiofrequency for postmastectomy pain A. Lukas, H. van Tinteren,S. Linn, E. Rutgers, N. Aaronson, R. Perez

Parameters T0T3wT 6wT6mT1y Sociaepidemiological and clinical dataxx Pain intensity rest/abduction [NRS]xxxxx Perceived effect [Likert scale]xxxx Analgesics [daily dose]xxxxx Adverse events & symptoms [VRS]xxxx QSTxxxxx Impact of pain on daily living [VRS]xxxxx Anxiety and depression [HADS]xxxxx Health related quality of life [SF-36]xxxxx Presumed received treatment Presumed applied treatment Expected effect (patient, interventionalist) XxXx x QST

Quantitative sensory testing - QST

Pilot met 24 patienten START maart 2010 Patientenrecrutering: Maandag Balie 4, LUK poli Alleen PMPS!!!! Analgesia and nerve function following pulsed radiofrequency for postmastectomy pain Lukas, H. van Tinteren,S. Linn, E. Rutgers, N. Aaronson, R. Perez

Chronic pain following breast surgery bothers 30% of patients is a complex syndrome due to nerve lesion, movement disorders of the shoulder and connective tissue changes has a lot of impact on the quality of life and recovery needs multidisciplinary diagnosis and treatment PRF might be a treatment option for neuropathic pain component ( as currently investigated in the AVL !)