Background & Aims
Cancer-associated brachial plexopathy is a rare condition that is often misdiagnosed or underdiagnosed. In breast cancer, brachial plexopathy is related to direct tumour invasion , metastasis related or radiation induced. Pain is the main disabling symptom in plexopathy secondary to tumor recurrence. Treatment options include symptomatic relief with medications and selective nerve blocks, chemotherapy or hormonal therapy to slow the progression of cancer, surgery and physical therapy interventions to help relieve the edema which may in turn, help with pain. Surgerical removal of tumor at the brachial plexus is an invasive procedures and harbors the risk of potential injury to other nerves.
This case report highlights the importance of early diagnosis and describes the management of pain secondary to brachial plexopathy from tumour metastasis in a patient with metastatic breast cancer.
Methods
47-year-old female patient with a history of metastatic breast cancer presented with left hand pain and swelling. On examination there was thenar muscle atrophy, weakness of finger movements and supraclavicular fossa fullness with tenderness.
Magnetic resonance imaging of the brachial plexus showed abnormal enhancement of the left brachial plexus, but was unable to differentiate between tumor recurrence or radiation induced changes. Nerve conduction study showed evidence of a left brachial plexopathy affecting the lower trunk. No myokymic discharges were seen in electromyography, suggesting tumor-related brachial plexopathy.
She underwent a nerve root block and pulsed radiofrequency at C8 and T1 nerve root, and ultrasound guided block to the brachial plexus. Her oral analgesics included tramadol and pregabalin. She participated in regular therapy sessions (physical, occupational – hand) for lymphatic massage, circulatory exercises, and was prescribed custom made pressure garment.
Results
The patient had minimal relief of her pain after the nerve root block and pulsed radiofrequency and brachial plexus block. Her condition worsened in the next 6 months resulting in loss of distal left hand function and poor Quality of Life ( QOL). She was continued on pharmacological agents for pain control, as well as carried on with therapy sessions to help teach her compensatory strategies for activities of daily living.
Conclusions
Perineural spread of breast cancer should be considered in patients even years after primary diagnosis in patients presenting with hand weakness and pain. If diagnosed early, surgical interventions or radiation therapy maybe considered for solitary lesions. Interventions like nerve root blocks and ultrasound guided brachial plexopathy block may or may not help with pain relief. Alongside pharmacological intervention, physical, occupational and hand therapy play mainstay role in managing pain and teaching compensatory strategies to the patient. There is definitely a growing need and role for research to develop more effective modalities such as laser irradiation, deep brain stimulation, transcranial direct stimulation to help relieve pain.
In conclusion, cancer associated brachial plexopathy is a progressively disabling condition. Early diagnosis and multidisciplinary approach with various therapeutic modalities is the key in pain management.
References
Susan R.H Brachial plexopathy after breast cancer: A persistent lateeffect of radiotherapy. PM&R 2024; 16:85-91
Christian M.C Electrodiagnosis in Cancer Rehabilitation. Phys Med Rehabil Clin N Am. 2017 February ; 28(1): 193–203.
Jack MM, Smith BW, Capek S, Marek T, Carter JM, Broski SM, Amrami KK, Spinner RJ. The spectrum of brachial plexopathy from perineural spread of breast cancer. J Neurosurg. 2022 Feb 25:1-10
Presenting Author
Trier Lau
Poster Authors
Topics
- Specific Pain Conditions/Pain in Specific Populations: Cancer Pain & Palliative Care