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1、 Cancer Pain SyndromesCraig D. Blinderman, MD, MACo-Director, MGH Cancer Pain ClinicMGH Palliative Care Service.ObjectivesReview the definition of pain and basic pathophysiologyReview the common causes of pain in cancer patientsReview approach to managing pain .Defining PainPain is defined as an unp

2、leasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.Merskey, H., Bogduk, N, ed. Classification of Chronic Pain, Second Edition. IASP Task Force on Taxonomy. 1994, IASP Press: Seattle. 209-214. .Taxonomy of PainClassificatio

3、n may be based on:AnatomyBody SystemTemporal Characteristics SeverityEtiologyPathophysiologyDefined pain syndromes .Taxonomy of PainClinically, it is useful to determine both the etiology and inferred pathophysiology in the assessment of the pain complaint, as this may suggest the use of specific th

4、erapies.Taxonomy of PainNociceptive Somatic VisceralNeuropathicPsychogenicIdiopathic .Nociceptive PainNociceptive somatic pain Sustained predominantly by tissue injury or inflammation. Described as sharp, aching, stabbing, throbbing or pressure-like. Nociceptive visceral pain Poorly localized; descr

5、ibed as crampy pain (e.g. obstruction of hollow viscus), or as aching and stabbing (e.g. pain secondary to splenomegaly). .Neuropathic PainSustained by abnormal somatosensory processing in the PNS or CNS. Typically, described as “burning,” “shock-like,” “electrical.”May be paroxysmal in nature. On p

6、hysical examination, patients may have allodynia (pain induced by non-painful stimuli) and hyperalgesia (increased perception of painful stimuli). .Psychogenic PainRefers to pain that is believed to be sustained predominantly by psychological factors. Rare in the cancer population. .Idiopathic PainI

7、n the absence of evidence sufficient to label pain as either nociceptive or neuropathic, we may use the term “idiopathic.” In patients with cancer, this term should lead to additional workup and a search for an underlying etiology and pathophysiology. .Basic Pathophysiology of PainTransduction Conve

8、rsion of thermal, chemical, mechanical stimulus to electrical activity at nociceptorNa channelsConductionPassage of action potential along the first order neuron to dorsal horn of spinal cordTransmissionTransfer and modulation of input from one neuron to another Substance P, Glutamate, Brain derived

9、 neurotropic factorInhibitory interneuronsPerceptionAwareness and meaning of painModulationDescending pathways inhibit transmission of nociceptive impulsese.g. Periaqueductal grey matter in midbrain-nucleus raphae in medullaNorepinephrine, serotonin, endogenous opioids . Ascending TractsDescending T

10、ractsCortexMidbrainMedullaSpinal CordThalamusPonsPeripheral and Central Pathways for PainModulationDescending pathways inhibit transmission of nociceptive impulsesPerceptionAwareness and meaning of painTransmissionTransfer and modulation of input from one neuron to another ConductionPassage of actio

11、n potential along the first order neuron to dorsal horn of spinal cordTransduction Conversion of thermal, chemical, mechanical stimulus to electrical activity at nociceptor.Cancer Pain Syndromes .Syndrome: DefinitionA temporal and qualitative convergence of symptoms and signs, which conforms to a re

12、cognized patternAssociated with distinct etiologies, pathophysiologies, and prognostic and therapeutic implications.Cancer Pain SyndromesRelated to tumor involvementAccounts for 78% of pain problems in inpatient cancer population and 62% of outpatient cancer population in MSKCC surveyMetastatic bone

13、 disease, hollow viscous involvement and nerve compression or infiltration are most common causesPain syndromes associated with cancer therapy19% of pain problems in inpatient population and 25% in outpatient populationPain unrelated to cancer or therapyApprox. 3% of inpatients have pain unrelated t

14、o their cancer and 10% in outpatient populationGeneralized pain in a dying cancer patientFoley, KM. Pain syndromes in patients with cancer. Oxford Textbook of Palliative Medicine, 3rd Ed.Cancer Pain Syndromes: Temporal PatternsTemporal ClassificationAcuteChronicBreakthrough Pain.Acute Cancer PainDef

15、ined by a recent onset and a natural history characterized by transience.May or may not be associated with overt pain behaviors.Usually caused by diagnostic or therapeutic interventions.Causes of Acute Cancer PainDiagnostic InterventionsAcute postoperative painTherapeutic interventionsAnalgesic Tech

16、niquesAssociated with chemotherapyAssociated with radiotherapyAcute pain associated with hormonal therapyAcute pain associated with immunotherapyAcute pain associated with infection.Chronic Cancer Pain Persists for one month or more beyond the usual course of an acute illness or injuryMost commonly

17、due to direct effects of the tumor Other causes: Due to cancer therapy (15-25%) Pathology unrelated to either the cancer or its treatment (5-15%).Causes of Chronic Cancer PainRelated to tumor involvementBone pain syndromesHeadache and Facial Pain Tumor involvement of the peripheral nervous systemVis

18、ceral pain syndromesIn neuroendocrine tumors with liver involvement this may be a major source of painSomatic soft tissue pain syndromesParaneoplastic pain syndromesPain syndromes associated with cancer therapyPost-chemotherapy pain syndromesChronic pain associated with hormonal therapyChronic post-surgical pain syndromesChronic post-radiation pain syndromes.Therapeutic strategy for cancer painNon-pharmacological ModalitiesCognitive behavioral interventionsMassage, Physical TherapyAcupuncture