Neuropathic cancer pain prevalence and characteristics in a palliative care population,

and proposal of a project for the validation of the EAPC diagnostic algorithm

Fabio FORMAGLIO Cinzia BRUNELLI Augusto CARACENI

Pain arising as a direct consequence of a lesion or disease affecting the somatosensory system

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Neuropathic pain

Neuropathic pain directly caused by tumours Bennett et al., 2012

Neuropathic cancer pain

Neuropathic cancer pain

Conclusion: Neuropathy was found to be a poor prognostic feature in advanced cancer pain management…

J Arthur et al., 2017

Conclusion: We found that NCP in cancer patients was significantly associated with a worsened QOL, and current management is inadequate…

SY Oh et al., 2017

Neuropathic pain in cancer patients prevalence

Pure neuropathic pain

Neuropathic Pain + mixed pain

Bennett et al., 2012

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Bennett et al., 2012

NeuPSIG, 2016

EAPC, 2014

PtsNeurological lesion or disease history

Neuroanatomical pain distribution

Sensory disorder signsInstrumental (radiological)

diagnostic confirm

1 Lumbosacral nerve roots infiltration Glutes, Thighs (Lumbo)Sacral dermatomes HypoesthesiaCT scan confirm of Cauda Equina infiltration

2 Lumbo - Sacral Plexus infiltration Gluteal, ThighDysesthesia - Hypoesthesia on Lower Lumbar - Sacral Plexus territories

CT scan confirm of Retroperitoneal and Pelvic region infiltrations

3Peripheral nerves of the arm infiltration

Arm, Forearm NormalMRI confirm of Median (Radial) nerves trunk infiltration

4 Sacral e Pudendal Plexus infiltration Glutes, Perineum NormalCT scan confirm of Pelvis and Perineum bilateral infiltrations

5Lower abdomen peripheral nerves and Lumbar Plexus infiltration

Lower abdomen, Groin

(doubtful) Groin Dysesthesia, (side absent response on Lower Superficial Abdominal Reflex)

CT scan confirm of Retroperitoneal infiltration

6Thoracic nerve roots and peripheral nerves infiltration

Chest, Flank NormalCT Scan confirm of Pleural and posterior Chest Wall infiltration

7LumboSacral and Pudendal Plexus infiltration

Perineum, ThighAllodynia and Hypoesthesia on Lumbar Plexus and / or Femoral nerve territory

CT scan confirm of Retroperitonal and Psoas muscle infilitration

8 Brachial Plexus infiltrationArmpit, Dorsum - Shoulder blade

Normal, (reduced Strenght in hand prehension)

CT Scan confirm of Lower Brachial Plexus infiltration

9 LumboSacral nerve roots infiltrationPelvis, posterior Thighs

Sacral dermatomes HypoesthesiaCT scan confirm of Lumbar spine methastases and Epidural invasion

10Pudendal and LumboSacral Plexus infiltration

Groin, Scrotum, Perineum

Groin AllodyniaPET scan confim Pelvic and Retroperitoneal disease

11 Cervical Plexus infiltration (Antero)Lateral neckCervical Plexus - Great Auricular Nerve territories hyposthesia

CT scan confim of Cervical Plexus infiltration

sss

sthesiaCT scan confirm of Cinfiltrationn

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Pain distribution

Patient 5 Colon cancer -> surgical resection. Retroperitoneal adenopathy Groin (lower abdominal) Left pain, uncontrolled with opioids Doubtful groin dysesthesia; absent left lower Superficial Abdominal Reflex Improved pain control with Pregabalin, Amytriptilne, Lidocaine patch

LumboSacral plexus

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LumboSacralplexus

Neuropathic cancer pain: conclusive messages

NCP diagnosis is difficult Cutaneous sensory disorders difficult to detect Neuropathic pain diagnostic algorithms reliability warrant

to be examined NCP distribution differs from non-cancer neuropathic pain NCP pathogenetic mechanisms, quality of pain and

treatment response could be different from non-cancer neuropathic pain

Molecule-to-man research programme on neuropathic pain 10 partners from 6 countries Horizon 2020, UE sponsor

Neuropathic pain in cancer patients clinical research • Epidemiology and characteristics of Neuropathic pain in tumors patients

• Clinical and QOL impact of neuropathic pain dedicated management • Neuropathic cancer pain management algorithm • EAPC / IASP neuropathic pain diagnostic algorithm validation in cancer patient