eMedicine Specialties > Physical Medicine and Rehabilitation > Plexopathy

Neoplastic Brachial Plexopathy: Treatment & Medication

Author: Mark A Wren, MD, MPH, Medical Director, Department of Physical Medicine and Rehabilitation, HealthSouth Rehabilitation Hospital of Texarkana
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Updated: Jan 19, 2010

Treatment

Rehabilitation Program

Physical Therapy

Physical therapy modalities also may be warranted for assisting in pain reduction in patients with NBP. Electrical modalities for pain control, such as transcutaneous electrical nerve stimulation (TENS) or interferential current, are reasonable but are considered to be a relative contraindication when applied directly over a malignant neoplasm. Edema control measures (eg, retrograde massage, elevation, compressive garments) may be considered. A sling or splint can help the patient maintain a comfortable position and protect the affected limb. A sling also can reduce edema, retard shoulder subluxation, and reduce additional traction on the brachial plexus.

Occupational Therapy

See the Physical Therapy section above. Completing a home safety evaluation for patients with NBP and their families is important. The home evaluation should include use of compensatory strategies and adaptive equipment to improve the patient's functional abilities. For example, a patient who can no longer perform bimanual skills may benefit from a device to help manipulate buttons in order to dress independently. The occupational therapist can work with the patient and maximize his/her capabilities in performing activities of daily living (ADL). The occupational therapist also can engage the patient in a sensory and motor re-education program if there is impaired function in the hand.

Speech Therapy

Though not directly related to plexopathies, metastatic neoplasm also may alter communication, swallowing, or cognitive function, requiring a speech therapy consultation.

Recreational Therapy

Recreational therapy can help to maintain the patient's interest and skills by incorporating leisure time activities into the rehabilitation program.

Medical Issues/Complications

For more severe lesions, an interdisciplinary approach may be most effective, including prescription of physical, occupational, and recreational therapies. Coordination of therapies, consultants, complications, and medications is needed.

Treatment often is difficult and may be palliative; chemotherapy and radiation therapy (up to 50% of patients obtain significant pain relief) are used if the tumor is sensitive to them. In the aforementioned investigation by Kamenova and colleagues (see Causes), 22 of the study's patients received BP treatment, aimed specifically at the locoregional metastases, with radiation therapy (8 patients) or endocrine treatment or chemotherapy (14 patients) initially being employed.⁵ In 19 of these patients, partial or complete remission of pain and neurologic deficits, lasting a median period of 8 months, occurred.

As the disease progresses, adequate pain control is the most important goal as most patients succumb to neoplastic involvement of vital organs within a few years.

Surgical Intervention

Several authorities advise referral of patients with NBP to surgeons with special expertise in treatment of NBP. Accurate diagnosis may prevent unnecessary surgery for carpal tunnel syndrome or thoracic outlet syndrome. Surgery usually is performed only for definite tissue diagnosis in secondary neoplasms. Primary tumors, like benign schwannomas, are encapsulated, permitting surgical excision without sacrificing adjacent nerves.

Most solitary neurofibromas can be resected without producing or increasing deficit, but this procedure is more difficult than excision of encapsulated tumors and usually requires magnification, intraoperative nerve action potential recording, and sometimes cable grafts. Some neurofibromas are "dumbbell tumors" that extend into the epidural space. Many benign tumors (including neurofibromas) can be removed without significant loss using surgical loupes or microscope and repetitive NAP recording. Plexiform neuromas are more difficult to remove because of extensive segments of nerve fiber involvement. Some elements may have to be sacrificed for pain control and to save the remainder of the plexus. In patients with severe intractable pain, dorsal rhizotomy, dorsal root entry zone surgery, or high contralateral percutaneous cordotomies can be considered. Amputation and other destructive procedures often are ineffective.

Consultations

Most patients have a consulting oncologist, as well as an internist or family practitioner. Some patients may need an anesthesiologist or interventional physiatrist for injections, and some may have seen a neurologist, or less commonly, a neurosurgeon (for more drastic measures mentioned above). Consultation with a psychologist may be helpful in terms of emotional adjustment, pain control, and supportive counseling.

Other Treatment

Paravertebral nerve blocks or other injection procedures may be indicated, depending on the location of the tumor(s). NBP often is widespread and is not amenable to application of selective blocks.

Medication

No medications are specific for this diagnostic entity. Typical analgesic and adjunct analgesic agents may be worthwhile in managing neoplastic plexopathy.

Opioid analgesics (eg, long-acting oxycodone or fentanyl) are associated with fewer concerns about tolerance and dependency than many other opiates. A ceiling effect is also absent with these agents, while use of combination agents like hydrocodone/acetaminophen may be limited by maximum dose of acetaminophen allowable (4 g/d). Opiates may be effective at acceptable doses and often are tried first. For more mild symptoms, topical analgesics should be tried.

Nonsteroidal anti-inflammatory drugs (NSAIDs) can be helpful and usually are tried in conjunction with other agents.

Adjunct agents such as tricyclic antidepressants (eg, nortriptyline, amitriptyline) or other antidepressants (eg, sertraline, venlafaxine), anticonvulsants (Lyrica, gabapentin, Tegretol), and, less commonly, antiarrhythmics (eg, mexiletine) may be used for control of neuropathic pain.

Opioid analgesic agents

Should be used early in the disease. As in most painful conditions, begin with low potency medications at low doses and taper to desired response.

Hydrocodone and acetaminophen (Vicodin, Lortab, Norcet)

Drug combination indicated for moderate to severe pain.

Oxycodone (OxyContin)

Indicated for the relief of moderate to severe pain.

Fentanyl (Duragesic)

Potent opioid analgesic with much shorter half-life than morphine sulfate. DOC for conscious sedation analgesia.
Excellent choice for pain management and sedation with short duration (30-60 min) and easy to titrate. Easily and quickly reversed by naloxone.

Corticosteroids

Can be helpful since inflammation may be part of the pathophysiology of the pain of NBP, as previously mentioned.

Prednisone (Deltasone, Orasone, Meticorten)

May decrease inflammation by reversing increased capillary permeability and suppressing PMN activity.

Cyclooxygenase-2 (COX-2) inhibitors

Although increased cost can be a negative factor, the incidence of costly and potentially fatal GI bleeds is clearly less with COX-2 inhibitors than with traditional NSAIDs. Ongoing analysis of cost avoidance of GI bleeds will further define the populations that will find COX-2 inhibitors the most beneficial.

Celecoxib (Celebrex)

Inhibits primarily COX-2. COX-2 is considered an inducible isoenzyme, induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited; thus, GI toxicity may be decreased. Seek lowest dose for each patient.

Nonsteroidal anti-inflammatory drugs

Have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclo-oxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions. Inexpensive older NSAIDs like ibuprofen or naproxen may be considered; however, COX-2 inhibitors with their lower GI toxicity are often first-line agents.

Ibuprofen (Motrin, Ibuprin)

DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Naproxen (Naprosyn, Naprelan, Anaprox)

For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclo-oxygenase, which results in a decrease of prostaglandin synthesis.

Tricyclic antidepressants

A complex group of drugs that have central and peripheral anticholinergic effects, as well as sedative effects. They have central effects on pain transmission and block the active reuptake of norepinephrine and serotonin.

Amitriptyline (Elavil)

Analgesic for certain chronic and neuropathic pain. Used as adjunct therapy.

Nortriptyline (Pamelor, Aventyl HCl)

Used as adjunct therapy. Has demonstrated effectiveness in the treatment of chronic pain. Used as adjunct agent.
By inhibiting the reuptake of serotonin and/or norepinephrine by the presynaptic neuronal membrane, this drug increases the synaptic concentration of these neurotransmitters in the CNS.
Pharmacodynamic effects such as the desensitization of adenyl cyclase and down-regulation of beta-adrenergic receptors and serotonin receptors also appear to play a role in its mechanisms of action.

Anticonvulsants

Use of certain antiepileptic drugs, such as the GABA analogue Neurontin (gabapentin), has proven helpful in some cases of neuropathic pain. Have central and peripheral anticholinergic effects, as well as sedative effects, and block the active reuptake of norepinephrine and serotonin. The multifactorial mechanism of analgesia could include improved sleep, altered perception of pain, and increase in pain threshold. Rarely should these drugs be used in treatment of acute pain, since a few weeks may be required for them to become effective.

Carbamazepine (Tegretol)

May reduce polysynaptic responses and block post-tetanic potentiation. Used as adjunct therapy.

Gabapentin (Neurontin)

Has anticonvulsant properties and antineuralgic effects; however, exact mechanism of action is unknown. Structurally related to GABA but does not interact with GABA receptors. There are no firm rules, but, in elderly patients, less potentially anticholinergic medications like gabapentin may be a good first choice. Used as adjunct therapy.

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