Clinical manifestations and diagnosis of postmastectomy pain syndrome
- Jeannie Shen, MD
Jeannie Shen, MD
- Clinical assistant Professor
- Division of Surgical Oncology
- UCLA Medical Center
- Section Editor
- Anees B Chagpar, MD, MSc, MA, MPH, MBA, FACS, FRCS(C)
Anees B Chagpar, MD, MSc, MA, MPH, MBA, FACS, FRCS(C)
- Section Editor — Breast Surgery
- Associate Professor, Department of Surgery
- Yale University School of Medicine
Postmastectomy pain syndrome (PMPS) is a type of chronic neuropathic pain disorder that can occur following breast cancer procedures, particularly those operations that remove tissue in the upper outer quadrant of the breast and/or axilla [1-5].
Pain can be severe enough to cause long-term disabilities and interfere with sleep, performance of daily activities including use of the affected arm, leading to shoulder adhesive capsulitis (frozen shoulder) or complex regional pain syndrome (causalgia) [4,6-10]. Altered sensation can also be observed within the distribution of the injured nerve, although not as debilitating as chronic pain . The pain can also seriously affect the patient’s mood, everyday activities, and social function, and create an economic burden for the healthcare system. (See "Frozen shoulder (adhesive capsulitis)" and "Complex regional pain syndrome in adults: Pathogenesis, clinical manifestations, and diagnosis".)
The definition of postmastectomy pain syndrome (PMPS) has not been standardized. PMPS is a type of neuropathic pain, a complex chronic pain state that is typically associated with nerve fiber injury. (See "Definition and pathogenesis of chronic pain".)
The pain is typically localized to the anterior/lateral chest wall, axilla, and/or medial upper arm and persisting more than three months after surgery when all other causes of pain, such as infection or recurrence, have been eliminated . The characteristics include classic features of neuropathic pain such as burning, tingling, shooting, stinging, or stabbing pains, and hyperesthesia .
Postmastectomy pain syndrome (PMPS) is caused by direct nerve injury (eg, severance, compression, ischemia, stretching, and retraction) during the breast cancer operation or from subsequent formation of a traumatic neuroma or scar tissue [5,6,12-15]. Different types of sensory disturbances (eg, tingling, burning, numbness) can result . Breast cancer operations can damage the brachial plexus, intercostobrachial, lateral cutaneous branch of the second intercostal, long thoracic, and medial and lateral pectoral nerves that innervate the breast, chest wall, and ipsilateral extremity (figure 1 and figure 2 and figure 3) [6,13]. In particular, surgical procedures in the upper outer quadrant of the breast and axilla, where major nerves traverse the operative field, are particularly vulnerable to nerve injury [15,16]. In addition, local radiation treatments and neurotoxic systemic therapy (eg, taxanes, platinum agents, vinca alkaloids) may also exacerbate PMPS [6-8,14,17,18].
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- RISK FACTORS
- Postoperative pain
- Age at diagnosis
- Axillary radiation
- Type of procedure
- Psychosocial factors
- CLINICAL FEATURES
- Clinical manifestations
- - Patient presentation
- - Physical examination
- Radiographic studies
- Laboratory studies
- Neurophysiologic testing
- DIFFERENTIAL DIAGNOSIS
- QUALITY OF LIFE
- SUMMARY AND RECOMMENDATIONS