PAIN-AFTER-BREAST-CANCER-SURGERY：乳腺癌手术后疼痛课件

TREATINGPAINAFTERSURGERYAndreaV.Barrio,MD,FACSAttendingBreastSurgeonAssociateProgramDirector,BreastFellowshipProgramTheBrynMawrHospitalINTRODUCTIONBreastcancermostcommoncanceramongwomenACSestimates232,340newcasesin2013¹Secondmostcommoncausedeath39,620deathsin2013¹Trendsin5Yr.survivalBREAST1975-19771984-19861996-2004CANCER75%79%89%¹PainaftersurgerySCOPEOFTHEPROBLEMEstimated2.9millionbreastcancersurvivors2012Persistentpostsurgicalpaindemonstratedin25-50%ofpatientsundergoingbreastcancersurgery¹Painaftersurgery:Introduction¹KehletH,Lancet,2006OVERVIEWAnatomyPresentationofbreastcancerCommonsurgicalproceduresforbreastcancerCausesofacutepost-surgicalpainCausesofpost-surgicalsensorydisturbancesLymphedemaTreatmentPainaftersurgeryBREASTANDAXILLARYANATOMYBREASTANATOMY

FemalebreastLobules(milk-producingglands)Ducts(tubescarrymilkfromlobulestonipple)Stroma(fattytissueandconnectivetissuesurroundingductsandlobules)PainaftersurgeryTHELYMPHATICSYSTEMPartofbody’sdefensesystemMostlymphaticvesselsinthebreastconnecttolymphnodesunderthearm(axillarynodes)Someconnecttolymphnodesinsidethechest(internalmammarynodes)andsometothoseabovethecollarbone(supraclavicularnodes)PainaftersurgeryPainaftersurgery:AnatomyPainaftersurgery:AnatomyHOWDOBREASTCANCERSPRESENT?BREASTCANCERPRESENTATIONImagingabnormalityMassCalcificationsArchitecturaldistortionPalpablelumpSkinchangesChangesinnippleRashNippledischargePainaftersurgeryBREASTCANCERPRESENTATIONImagingabnormalityMassCalcificationsArchitecturaldistortionPalpablelumpSkinchangesChangesinnippleRashNippledischargePainaftersurgeryBREASTCANCERPRESENTATIONImagingabnormalityMassCalcificationsArchitecturaldistortionPalpablelumpSkinchangesChangesinnippleRashNippledischargePainaftersurgeryDiagnosisusuallymadewithimage-guidedbiopsyIMAGE-GUIDEDBREASTBIOPSYMinimallyinvasivebiopsystandardofcareforinitialdiagnosisofimagingabnormalitiesHematomaafterbiopsycanoftencausesignificantdiscomfort/painPainaftersurgeryCANIDECREASEMYCHANCESOFHAVINGAPOST-BIOPSYHEMATOMA?OftenunavoidableAvoidbloodthinnersCoumadinAnti-plateletsAspirin?VitaminEFishoilPainaftersurgerySURGICALPROCEDURESOFTHEBREASTLUMPECTOMYIncisionismadeonthebreastRemovesthebreastcancerwitharimofnormaltissuePainaftersurgeryRADIATIONTHERAPYTreatmentwithhighenergyraysthatdestroycancercellsThetreatmentisusedtokillcancercellsthatremaininthebreastTreatmentwithlumpectomyisalmostalwaysfollowedbyradiationtherapyRadiationtherapydecreasesthelikelihoodofthecancercomingbackinthebreastbymorethan50%PainaftersurgeryMASTECTOMYRemovaloftheentirebreastincludingthenippleandareola,leavingthepectoralismajorintactWithamastectomy,radiationisusuallynotnecessaryPainaftersurgerySURGICALPROCEDURESOFTHEAXILLAAXILLARYLYMPHNODEDISSECTIONAnimportantpartofstagingbreastcancerisdeterminingifthelymphnodesunderthearmareinvolvedwithcancer10–40lymphnodesareremovedduringastandardALNDWasoncestandardofcareforbreastcancerpatientsPainaftersurgerySENTINELLYMPHNODEBIOPSYSentinellymphnodeisthefirstlymphnodetoreceivedrainagefromthebreastoratumorinthebreastInjectionofradiotracer+/-bluedyeintotheskinAgammaprobeusedtodetectradioactivityintheaxillaOnlynodesthatarehotand/orblueareremovedPainaftersurgeryCAUSESOFACUTEPOST-SURGICALPAINCELLULITIS/ABSCESSPost-operativeinfectionrare,butcanoccurinbreastoraxillaIfsuperficial,cantreatwithantibioticsIfdeeperinfectionsuspected,mayrequireincisionanddrainageofinfectedfluidPainaftersurgeryMONDOR’SDISEASEThrombosisofsuperficialveinPresentsasafirmtendercordoftissueusuallyfromupperabdomentolowerpartofbreastMayoccurafterbreastsurgerySelf-limited(resolveswithin2-8weeks)Treatment:HeatAnti-inflammatorymedicationPainaftersurgerySEROMACollectionoffluidinsurgicalcavityNormalpartofwoundhealingSeromamaybecometenseandpainful,particularlyinaxillaTreatment:SimpleaspirationRepeatedasnecessaryPainaftersurgeryAXILLARYWEBSYNDROMECanbeseenafteranyaxillarysurgeryPresentsasaseriesoftender,cord-likestructuresthatarevisibleandpalpablebeneathaxillaryskinCordscanextenddownthearm,intoforearmPainaftersurgeryAXILLARYWEBSYNDROME“Cording”duetodisruptionoflymphaticvesselsduringaxillarysurgeryIncidence:20%aftersentinelnodebiopsy44%-72%afteraxillarynodedissectionDevelopsinearlypost-operativeperiodLimitsrangeofmotionTreatment:PHYSICALTHERAPYtoimprovesymptomsandshortencoursePainaftersurgerySHOULDERABDUCTIONMORBIDITYAfteraxillarysurgery,rangeofmotioninshouldermaybesignificantlylimitedMaybedueto:PainScartissueAxillarywebsyndromeStudydemonstratedshoulderdeficits1weekaftersurgery¹:41%afterSLNbiopsy75%afterALNDSymptomsweresignificantlyimproved6monthsaftersurgeryPainaftersurgery¹AshikagaT,JSO,2010CAUSESOFPOST-SURGICALSENSORYDISTURBANCESBRACHIALPLEXOPATHYUsuallyrelatedtooperativepositioningInvolvesparesisofarmwithsensorychangesdistinctfromminorsensorydisturbancescausedbyinjurytointercostobrachialnervePrevention:AppropriatepositioningincludingavoidinghyperextensionofthearmTreatment:PhysicaltherapyPainaftersurgeryNUMBNESSAtincisionsiteafterlumpectomyorlymphnodebiopsyOfskinaftermastectomyInnerarmafterlymphnodebiopsyIntercostobrachialnerveoftensacrificedduringaxillarydissectionEvenifpreserved,maybestretchedorinjuredPainaftersurgeryNUMBNESSIfnerveissacrificed:Numbnessunderarmremains,butsymptomsbecomesignificantlylessdistressingIfnerveissimplystretched:Normalsensationtotheinnerarmwillreturn,butmaytakeseveralmonthsPainaftersurgeryPHANTOMBREASTPAINMostcommonaftermastectomyJohnsHopkinsstudyreported39%womenhadphantomsensationsaftermastectomyIncidencewassimilarwithorwithoutreconstructionDuringmastectomy,smallnervesbetweenbreastandskinarecutPhantomsensationsmayberelatedtoalteredconnectionbetweenthecutnerveandthebrainPainaftersurgeryPHANTOMBREASTPAINCommonsensationsreported:PainanddiscomfortItchingPinsandneedlesTinglingPressureBurningThrobbingTreatment:Exerciseor“breast”massagemayhelpPainmedicationforseverecasesPainaftersurgery18SENSATIONSAFTERBREASTCANCERSURGERY187patientswithbreastcancercompletedquestionnaireat3,6,12,24and60monthsaftersurgery141lumpectomy46mastectomyAllhadaxillarysurgery133sentinelnodebiopsy54axillarylymphnodedissectionPainaftersurgeryBaronR,ASO,200618SENSATIONSAFTERBREASTCANCERSURGERYTenderSorePullAcePainfulTwingeTightStiffPrickThrobShootTingleNumbBurnHardSharpNagPenetratePainaftersurgeryBaronR,ASO,200618SENSATIONSAFTERBREASTCANCERSURGERYMostprevalentsensationsatbaseline=tendernessSensationslessprevalentandlesssevereaftersentinelnodebiopsycomparedtoaxillarydissectionSomesensationswereprevalent,evenat5yearsTendernessandtwingesafterSLNbiopsyTightnessandnumbnessafterALNDPainaftersurgeryBaronR,ASO,200618SENSATIONSAFTERBREASTCANCERSURGERYStudyprovidesvaluableimportantinformationregardingwhatistobenormalandexpectedpartofhealingprocessMostsensationsobserved,evenifprevalent,werenotsevereordistressingPainaftersurgeryBaronR,ASO,2006LYMPHEDEMAPotentialcauseofpost-surgicalpainLimbswellingoccursasaresultofproteinrichfluidaccumulatinginthesofttissuesAdditionalfluidbuild-upinarmcancausetingling,achingandheavinessIncidence3-16%ofwomenundergoingaxillarysurgeryPainaftersurgeryRISKFACTORSFORLYMPHEDEMAManyretrospectivestudiesevaluatingassociationbetweenriskfactorsandlymphedema1AxillarylymphnodedissectionMastectomyObesityRadiationInfectionIpsilateralupperextremityinjuryRecentstudyreportedthatsaunausewasonlylifestyleriskfactorassociatedwithlymphedema²1McLaughlinSA,Oncology,2012²ShowalterS,ASO,2013PainaftersurgeryTREATMENT/TIPSTOREDUCESYMPTOMSPOST-OPERATIVEEXERCISEEarlypost-operativeexercisemostimportantInareviewof10studies,introductionofupperextremityexerciseasearlyaspost-operativeday1afteraxillarysurgeryshowedclearbenefitoverdelayed(day5-7)forshoulderrangeofmotion¹Structuredexerciseprogramswithaphysicaltherapistsignificantlyimprovepost-operativerangeofmotionandshoulderdysfunction¹Painaftersurgery¹McNeelyM,Cochranereview,2010PHYSICALTH