Mechanisms of Cancer Pain

Mechanisms of Cancer Pain Prof.dr.Kris C.P.Vissers, M.D., Ph.D., FIPP Department of Anesthesiology, Pain and Palliative Medicine University Medical Centre St Radboud Nijmegen Pain: important symptom in oncological states • Pain is most prominent symptom in oncological states • Present in • • • 30 – 40 % of cases on diagnosis 40 – 70 % of cases during treatment 70 – 90 % of cases in terminal (supportive) care Steven Wolff, Winston Parris 2 Prevalence of cancer pain:: Type of cancer and prevalence of pain: Thoracic Lung Bone Mouth Gastrointestinal Genitourinary tract (male) Genirourinary tract (woman) Lymphoma Leucemia 52 % 45 % 85 % 80 % 40 % 75 % 70 % 20 % 5% Oxford Textbook of Palliative Care 3 Types of Cancer Pain: Pain induced by Tumor or neoplasm 77 – 80 % • • • Bone pain Compression of spinal cord / other structures Peripheral neuropathic pain • Visceral pain Sloan Kettering Cancer Centre 4 Types of Cancer Pain: Pain induced by Cancer Pain Treatment 15 – 25 % • • • • • • • • Post-surgical pain Postamputation pain Post-thoracotomy pain Post-mastectomy pain Post-chemotherapy pain (neuropathy) Post-radiation pain syndromes (plexopathy, myelopathy) Post-radiation induced nerve tumor Paraneoplastic pain syndromes • Pain of other origins ( non-cancer related pain) 3 – 5 % • Pain of unknown origin 5 Types of Cancer Pain: • Cancer pain is a nociceptive composition of • • • • Acute pain Chronic pain Cancer-related pain Pain related due to oncological treatments • Inbedded in a psychodynamic proces 6 Influencing factors of cancer pain • Other somatic symptoms (chronic cough, nausea, hikup) • Knowledge and understanding of the patiënt • Feelings of frustrations, angry and depression • Social factors ( financial, partner, children) • Existential problems • Cultural factors 7 Mechanisms of Cancer pain: Pain neuromatrix Input in body neuromatrix of: Output towards brain site responsible for: Cognitive brain sites Pain perception C Sensorial conduction system S Action programming Emotional systems E Stress-related programms time time Modified Loeser Melzack R MD Consult 2003 8 Peripheral nociceptors: 9 Nociceptor: Signal transduction stimulation electrical stimulation 10 Nerve conduction: primary and secundary pain 11 Pain transmisison 12 Types of Cancer Pain: • Nociceptive pain: ongoing tissue injury in somatic structures • Neuropathic pain: aberrant somatosensory processing • Visceral pain: damage of visceral structures 13 nociceptive pain 14 inflammatory pain 15 neuropatic pain Lesion in the pain processing system 16 Pain Receptors Zang, 2006 17 Bone Cancer Model ( Mantyh) 18 Induction of Bone Cancer Pain: local reaction Goblirsch, 2005 19 Bone Cancer Pain: spinal conduction 20 Increase in astrocytes at the fourth lumbar level spinal cord after injection of osteolytic tumor 2472 intrafemoral 21 Neurochemical Alterations: Specificity of Cancer Pain • 22 Neurochemical alterations 23 Int J Cancer 2003 24 Neurochemical changes in central nervous system in different tumors 25 Pancreatic tumors, innervation and pain behavior 26 Conclusions: • Pain is a common symptom of cancer • Delineate type of cancer: nociceptive, neuropathic, visceral • Local tumors cause spinal and supraspinal hyperreactivity • Different tumors cause different spinal pain reactivity • Depending on stage pain is increasing k.vissers@anes.umcn.nl 27