Post-Mastectomy Pain Syndrome (PMPS)
Post mastectomy pain syndrome (PMPS) consists of persistent pain in the anterior chest, axilla, medial and posterior parts of the arm following breast surgery for breast cancer, including radical mastectomy and segmental mastectomy (lumpectomy). PMPS is predominantly a neuropathic (nerve) pain, commonly described as an electric shock-like pain sensation associated with a continuous aching or burning. Often there is also the presence of chronic dysesthesia, when touching the affected part of the body causes inappropriate, often unpleasant sensation, such as burning or tingling.
PMPS pain can be severe enough to interfere with quality of life, including impaired sleep and performance of daily activities. Patients may develop an immobilized arm, leading to severe lymph edema, frozen shoulder syndrome, and complex regional pain syndrome. Pain typically begins in the immediate postoperative period but may be delayed six or more months after surgery.
Definitions and Terms Related to Pain
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Post-Mastectomy Pain Syndrome
The incidence of PMPS varies with reports as low as 6% to as high as 100%. Chronic pain in PMPS can be nociceptive – resulting from damage to muscles and ligaments; and neuropathic – resulting from damaged nerves or dysfunction of the nervous system. Because it is believed that nerve injury occurs in 80-100% of mastectomy patients who undergo an axillary dissection, treatment is directed mostly at controlling nerve pain.
There are four subtypes or sources of neuropathic pain in PMPS:
- Phantom breast pain – painful sensation on the breast that has been removed;
- Intercostobrachial neuralgia – defined as pain and sensitivity changes in the distribution of the intercostobrachial nerve with symptoms varying according to where the nerve was severed. The most common cause of PMPS is damage to the intercostobrachial nerve, the lateral cutaneous branch of the second intercostal nerve, that is often resected at mastectomy;
- Pain secondary to the presence of a neuroma – neuromas are not true neoplasms but hyperplastic proliferations of neuronal and fibrous connective tissue that occur in response to nerve injury, including pain in the surgical scar, thorax, or arm;
- Pain due to damage to other nerves – resulting from damage or even traction of the medial pectoral, lateral pectoral, thoracodorsal, and long thoracic nerves.
Phantom Breast Pain
Phantom breast syndrome is a condition in which patients have a sensation of residual breast tissue and can include both non-painful and painful sensations. The incidence ranges from 30% to 80% of patients after mastectomy. Phantom pain is a variant of neuropathic pain likely representing dysfunction of the nervous system as opposed to local nerve damage. Studies support the potential benefit of memantine, a NMDA antagonist, in the management of phantom limp pain. There is no pharmacologic pain management specific for phantom pain apart from usual neuropathic pain management.
Mirror box therapy is a very specific type of physical therapy (PT) with proven effectiveness for patients with post-amputation phantom limb pain in which the patient watches in a mirror while receiving PT to re-map the brain’s neural pathways and register that the limb is no longer there. Studies are lacking to establish effectiveness for mirrox box therapy for phantom breast pain.
In rare cases, PMPS pain can result from the development of neuromas of the intercostal nerves severed during surgery. Traumatic neuromas are rare benign lesions that occur at the proximal end of a severed nerve. A neuroma can present s a localized area of pain along the lateral chest wall that can be triggered by tapping on it, eliciting a pain that will refer along the distribution of the affected nerve (Tinel’s sign). When identified, a local anesthetic block can temporarily relieve the pain and confirm the likely diagnosis. Considered a superior technique to mammagram or MRI for identifying a neuroma, an ultrasound evaluation can further confirm the diagnosis.
Definitive treatmen can be obtained with a surgical excision of the neuroma. Radiofrequency ablations (RFA) have also be used to treat neuromas. Medical management of neuroma pain includes topical counterirritants (capsacian and mentholated creams). Caspacian cream acts by interrupting transmission of pain impulses through small diameter nerves by decreasing substance P (a neurotransmitter) and has been found to be effective in patients with neuromas. Neuromas in scars may respond to injections of corticosteroids.
Management of PMPS
Different therapies have been used for PMPS including medications (antidepressants, NSAIDS, antiepileptics, opioids, NMDA receptor antagonists including memantine, cannabanoids, lidocaine, magnesium and adenosine), peripheral nerve stimulation and spinal cord stimulation, nerve blocks and surgery.
Pain derived from damaged muscles andligaments, characterized as nociceptive pain, is generally described as dull, aching, throbbing, pressure or stabbing. This type of pain is likely to resp0nd to NSAIDs, topical anesthetics and opioids.
Neuromodular agents directed at nerve pain include gabapentin (Neurontin) and pregabalin (Lyrica) and tricyclic antidepressants that work independently and unrelated to depression, incuding amitriptyline (Elavil), doxepin and others. Gabapentin is often the first-choice drug for relieving allodynia (sensations perceived as painful that are not normally painful) and hyperalgesia (normally painful sensations perceived as very painful), but it is usually less effective for decreasing paresthesia (tingling) and dysesthesia. A combination of gabapentin and amitriptyline is particularly effective synergistically.
Topical agents may offer significant benefit, including compounded formulas containing ketamine, a NMDA antagonist, gabapentin, amitriptyline and/or lidocaine.
Opioids vary in their effectiveness for neuropathic pain. Better choices may include tapentadol (Nucynta), fentanyl and lovorphanol or methadone (See: opioids). Topical agents including ketamine can be compounded in synergistic combinations with anesthetics and antidepressants that can also be helpful.
See: Neuropathic Pain
Interventional procedures offered for managing PMPS include the use of regional nerve blocks, peripheral stimulators and spinal cord stimulators.
Stellate Ganglion Blocks
Performed under guided fluoroscopy with sedation, use of a stellate ganglion (SG) block can be an effective therapeutic option for PMPS. Benefits form SG blocks may persist fro 3 months or longer. A 2008 study comparing effectiveness of SG blocks and gabapentin revealed gabapentin to be superior in long term pain control and sleep although SG blocks appeared to provide better quality of life presumably to lack of medication side effects sometimes found with gabapentin. Certainly, however, both approaches can be offered together and may result in the need for lower doses of gabapentin and therefore less side effects.
In addition to pharmacologic and interventional treatments, studies have shown the importance of adjunctive therapies to improve the physical and psychological health of women diagnosed with PMPS. Acupuncture has been shown to significantly increase the range of arm motion, and reduce PMPS pain following axillary dissection.
Other suggested modalities include:
- Guided imagery training and medical hypnosis (See: hypnosis)
- Physical therapy to prevent “frozen shoulder” syndrome. (See: Physical Therapy)
- Cognitive Behavior Therapy and psychological counseling has also been shown as effective in improving both comfort and function. (See: CBT)
It is difficult to secure a prognosis for individuals with PMPS but one study reported that while pain can persist for years, approximately 50% of patients will experience significant relief or resolution of pain within four years.
Post-Mastectomy Pain – Overviews
- Post Breast Therapy Pain Syndrome (PBTPS)
- Post-Mastectomy Pain Syndrome -The Magnitude of the Problem – 2009
Post-Mastectomy Pain – Gabapentin & Pregabalin
- Comparing the Effect of Stellate Ganglion Block and Gabapentin on the Post Mastectomy Pain Syndrome. – 2008
Post-Mastectomy Pain – Neuromas
- Intercostal neuroma as a source of pain after aesthetic and reconstructive breast implant surgery. – PubMed – 2012 NCBI
- Intercostal neuromas: a treatable cause of postoperative breast surgery pain. 2001 – PubMed – NCBI
- Imaging Features Associated With Posttraumatic Breast Neuromas. 2016 – PubMed – NCBI
- Ultrasonographic features of traumatic neuromas in breast cancer patients after mastectomy – 2017
Post-Mastectomy Pain – Phantom Breast Pain
- Phantom Breast Syndrome – 2009
- Memantine for the Treatment of Phantom Limb Pain: A Systematic Review. 2016 – PubMed – NCBI
- Profound Pain Reduction After Induction of Memantine Treatment in Two Patients with Severe Phantom Limb Pain – 2008
- Pharmacologic interventions for treating phantom limb pain (Review) – 2016
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