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Clinical manifestations and diagnosis of postmastectomy pain syndrome

Jeannie Shen, MD
Section Editor
Anees B Chagpar, MD, MSc, MA, MPH, MBA, FACS, FRCS(C)
Deputy Editor
Wenliang Chen, MD, PhD


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 [10]. 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 [11]. The characteristics include classic features of neuropathic pain such as burning, tingling, shooting, stinging, or stabbing pains, and hyperesthesia [12].  


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 [11]. 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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Literature review current through: Sep 2016. | This topic last updated: Mar 2, 2015.
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  1. Gärtner R, Jensen MB, Nielsen J, et al. Prevalence of and factors associated with persistent pain following breast cancer surgery. JAMA 2009; 302:1985.
  2. Caviggioli F, Maione L, Forcellini D, et al. Autologous fat graft in postmastectomy pain syndrome. Plast Reconstr Surg 2011; 128:349.
  3. Stubblefield MD, Custodio CM. Upper-extremity pain disorders in breast cancer. Arch Phys Med Rehabil 2006; 87:S96.
  4. Smith WC, Bourne D, Squair J, et al. A retrospective cohort study of post mastectomy pain syndrome. Pain 1999; 83:91.
  5. Miguel R, Kuhn AM, Shons AR, et al. The effect of sentinel node selective axillary lymphadenectomy on the incidence of postmastectomy pain syndrome. Cancer Control 2001; 8:427.
  6. Caffo O, Amichetti M, Ferro A, et al. Pain and quality of life after surgery for breast cancer. Breast Cancer Res Treat 2003; 80:39.
  7. Tasmuth T, von Smitten K, Hietanen P, et al. Pain and other symptoms after different treatment modalities of breast cancer. Ann Oncol 1995; 6:453.
  8. Bokhari F, Sawatzky JA. Chronic neuropathic pain in women after breast cancer treatment. Pain Manag Nurs 2009; 10:197.
  9. Polinsky ML. Functional status of long-term breast cancer survivors: demonstrating chronicity. Health Soc Work 1994; 19:165.
  10. Macdonald L, Bruce J, Scott NW, et al. Long-term follow-up of breast cancer survivors with post-mastectomy pain syndrome. Br J Cancer 2005; 92:225.
  11. Meijuan Y, Zhiyou P, Yuwen T, et al. A retrospective study of postmastectomy pain syndrome: incidence, characteristics, risk factors, and influence on quality of life. ScientificWorldJournal 2013; 2013:159732.
  12. Jung BF, Ahrendt GM, Oaklander AL, Dworkin RH. Neuropathic pain following breast cancer surgery: proposed classification and research update. Pain 2003; 104:1.
  13. Wallace MS, Wallace AM, Lee J, Dobke MK. Pain after breast surgery: a survey of 282 women. Pain 1996; 66:195.
  14. Steegers MA, Wolters B, Evers AW, et al. Effect of axillary lymph node dissection on prevalence and intensity of chronic and phantom pain after breast cancer surgery. J Pain 2008; 9:813.
  15. Vecht CJ, Van de Brand HJ, Wajer OJ. Post-axillary dissection pain in breast cancer due to a lesion of the intercostobrachial nerve. Pain 1989; 38:171.
  16. Wong L. Intercostal neuromas: a treatable cause of postoperative breast surgery pain. Ann Plast Surg 2001; 46:481.
  17. Poleshuck EL, Katz J, Andrus CH, et al. Risk factors for chronic pain following breast cancer surgery: a prospective study. J Pain 2006; 7:626.
  18. Tasmuth T, Kataja M, Blomqvist C, et al. Treatment-related factors predisposing to chronic pain in patients with breast cancer--a multivariate approach. Acta Oncol 1997; 36:625.
  19. Vilholm OJ, Cold S, Rasmussen L, Sindrup SH. The postmastectomy pain syndrome: an epidemiological study on the prevalence of chronic pain after surgery for breast cancer. Br J Cancer 2008; 99:604.
  20. Vadivelu N, Schreck M, Lopez J, et al. Pain after mastectomy and breast reconstruction. Am Surg 2008; 74:285.
  21. Sclafani LM, Baron RH. Sentinel lymph node biopsy and axillary dissection: added morbidity of the arm, shoulder and chest wall after mastectomy and reconstruction. Cancer J 2008; 14:216.
  22. Hack TF, Cohen L, Katz J, et al. Physical and psychological morbidity after axillary lymph node dissection for breast cancer. J Clin Oncol 1999; 17:143.
  23. Mejdahl MK, Andersen KG, Gärtner R, et al. Persistent pain and sensory disturbances after treatment for breast cancer: six year nationwide follow-up study. BMJ 2013; 346:f1865.
  24. Katz J, Poleshuck EL, Andrus CH, et al. Risk factors for acute pain and its persistence following breast cancer surgery. Pain 2005; 119:16.
  25. Andersen KG, Kehlet H. Persistent pain after breast cancer treatment: a critical review of risk factors and strategies for prevention. J Pain 2011; 12:725.
  26. Ververs JM, Roumen RM, Vingerhoets AJ, et al. Risk, severity and predictors of physical and psychological morbidity after axillary lymph node dissection for breast cancer. Eur J Cancer 2001; 37:991.
  27. Fecho K, Miller NR, Merritt SA, et al. Acute and persistent postoperative pain after breast surgery. Pain Med 2009; 10:708.
  28. Glechner A, Wöckel A, Gartlehner G, et al. Sentinel lymph node dissection only versus complete axillary lymph node dissection in early invasive breast cancer: a systematic review and meta-analysis. Eur J Cancer 2013; 49:812.
  29. Belfer I, Schreiber KL, Shaffer JR, et al. Persistent postmastectomy pain in breast cancer survivors: analysis of clinical, demographic, and psychosocial factors. J Pain 2013; 14:1185.
  30. Schreiber KL, Martel MO, Shnol H, et al. Persistent pain in postmastectomy patients: comparison of psychophysical, medical, surgical, and psychosocial characteristics between patients with and without pain. Pain 2013; 154:660.
  31. Legeby M, Segerdahl M, Sandelin K, et al. Immediate reconstruction in breast cancer surgery requires intensive post-operative pain treatment but the effects of axillary dissection may be more predictive of chronic pain. Breast 2002; 11:156.
  32. Henderson JR, Tao A, Kirwan CC, Barr L. Immediate breast reconstruction does not increase postmastectomy pain. Ann Surg Oncol 2014; 21:113.
  33. Ilfeld BM, Madison SJ, Suresh PJ, et al. Persistent postmastectomy pain and pain-related physical and emotional functioning with and without a continuous paravertebral nerve block: a prospective 1-year follow-up assessment of a randomized, triple-masked, placebo-controlled study. Ann Surg Oncol 2015; 22:2017.
  34. Basen-Engquist K, Hughes D, Perkins H, et al. Dimensions of physical activity and their relationship to physical and emotional symptoms in breast cancer survivors. J Cancer Surviv 2008; 2:253.
  35. Tasmuth T, Blomqvist C, Kalso E. Chronic post-treatment symptoms in patients with breast cancer operated in different surgical units. Eur J Surg Oncol 1999; 25:38.
  36. Meretoja TJ, Leidenius MH, Tasmuth T, et al. Pain at 12 months after surgery for breast cancer. JAMA 2014; 311:90.
  37. Rietman JS, Dijkstra PU, Debreczeni R, et al. Impairments, disabilities and health related quality of life after treatment for breast cancer: a follow-up study 2.7 years after surgery. Disabil Rehabil 2004; 26:78.
  38. Sugden EM, Rezvani M, Harrison JM, Hughes LK. Shoulder movement after the treatment of early stage breast cancer. Clin Oncol (R Coll Radiol) 1998; 10:173.
  39. Lauridsen MC, Overgaard M, Overgaard J, et al. Shoulder disability and late symptoms following surgery for early breast cancer. Acta Oncol 2008; 47:569.
  40. Nesvold IL, Dahl AA, Løkkevik E, et al. Arm and shoulder morbidity in breast cancer patients after breast-conserving therapy versus mastectomy. Acta Oncol 2008; 47:835.
  41. Merchant CR, Chapman T, Kilbreath SL, et al. Decreased muscle strength following management of breast cancer. Disabil Rehabil 2008; 30:1098.
  42. Dijkstra PU, Rietman JS, Geertzen JH. Phantom breast sensations and phantom breast pain: a 2-year prospective study and a methodological analysis of literature. Eur J Pain 2007; 11:99.
  43. Krøner K, Knudsen UB, Lundby L, Hvid H. Long-term phantom breast syndrome after mastectomy. Clin J Pain 1992; 8:346.
  44. Reuben SS, Makari-Judson G, Lurie SD. Evaluation of efficacy of the perioperative administration of venlafaxine XR in the prevention of postmastectomy pain syndrome. J Pain Symptom Manage 2004; 27:133.