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Pain in early cancer of the lungs
Pain, 21(1986) Elsevier
57
V-62
PAI 00943
Pain in Early Cancer of the Lungs Carlo Marino *, Massimo Zoppi **,l, Franc0 Morelli *, Umberto Buoncristiano *** and Elio Pagni *** * Department of Pneumologv, Local Sanifa~ Unir IO-D, Florence, ** Institute of Clinical Medicine, University of Florence, Florence, and * * * Department of Anesthesiology, Local Sanitaty Unit IO-H, Florence (Italy) (Received
17 July 1985, revised received 23 January
1986, accepted
6 February
1986)
Summary spread or 164 patients with early cancer of the lungs, i.e., without extrathoracic distant metastasis, were examined. Subjective and objective characteristics of the pain were studied. A correlation was found between the location of the neoplasm, the location of the pain and the characteristics of the sensory changes. These observations may be a useful contribution to the early diagnosis of primary carcinomas of the lungs.
Introduction Previous studies of our center on pain in patients with cancer of the lungs were carried out by Teodori and Galletti [5] who observed that pain was present in 80% of the patients with lung neoplasms. The pain was always referred to the thoracobrachial regions, with the following clinical patterns: (i) Early onset pain, referred to the side of the affected lung, prevalently the acromion, deltoid and scapular regions, accompanied by cutaneous hyperalgesia within the dermatomes T,-T, and by deep hyperalgesia of thoracic muscles such as the deltoid, pectoralis major and infraspinous. (ii) Late, intense, badly tolerated pain, diffusely affecting the chest and the shoulders, with pleuric, periosteal and nervous involvement.
’ Address correspondence to: Massimo Zoppi, Viale Morgagni, 50134 Florence, Italy.
0304-3959/86/$03.50
Institute
0 1986 Elsevier Science Publishers
of Clinical
Medicine,
B.V. (Biomedical
University
Division)
of Florence,
58
The research of Teodori and Galletti was carried out mainly on advanced tumors. and the onset of the pain was deduced from the history. A more recent study was limited to the description of the subjective location of the pain. Its intensity and accompanying signs were not investigated [6]. The present study was carried out on the patients with early and primary neoplasms of the lungs at the time of diagnosis. Patients in whom the diagnosis was made during previous periods of hospitalization or patients with advanced tumors such as extrathoracic spread, rib metastasis, brachial plexus and pleural involvement, were excluded. In this way it was possible to observe and describe the pain at its earliest objective and subjective manifestations.
Method
Over a period of 8 months, we examined 164 patients (143 males and 21 females, aged between 49 and 81 years) who were hospitalized in the Department of Pneumology. In all these patients the diagnosis of primary carcinoma of the lungs without extrathoracic spread or distant metastasis was made by means of standard examinations (roentgenograms, fiber optic bronchoscopy, sputum cytology, etc.). 80% of the patients underwent chest surgery. The location and histology of the neoplasm in all these patients was confirmed. The incidence of chest pain was observed. In the subjects with pain, location, intensity, quality, depth, onset and temporal pattern were recorded. The intensity of the pain was studied using the numerical scale, according to Keele [3], and a vertical visual analogue scale of 10 cm according to Huskisson [l] and Scott and Huskisson [4]. At the bottom of this scale the classification was ‘no pain’ (‘nessun dolore ‘), and at the top ‘pain as bad as it could be’ (‘il dolore pill forte immuginabile
‘).
In the patients with pain, the chest was examined: (i) By dragging a needle-point along the skin, at a constant pressure and speed. This stimulus was applied at many sites on the (anterior and posterior) chest, back and upper limbs, stroking in both upward and downward directions along the entire length. With this method it was possible to observe the presence and the location of cutaneous hyperalgesia; (ii) By applying various degrees of digital pressure to define the zones of muscular tenderness within the areas of spontaneous pain and of cutaneous hyperalgesia. The entire procedure was as follows: one of the investigators selected the patients with pain; another investigated the subjective and objective characteristics of the pain without knowing the location or histology of the neoplasm; and at the end of the investigation a third investigator correlated the clinical data with the sensory findings.
59
Results
Pain was present in 65 patients (59 males and 6 females: 40% of the total). The higher incidence of pain was found in the patients aged 65-69 years (20 subjects). In the patients with pain, the histological pattern is shown in Table I. The location of the neoplasm studied with roentgenograms is shown in Table II. The spontaneous pain was felt on the side of the neoplasm in 80% of the patients and was bilateral in the remaining 20%. It was continuous in 22 patients, showed remission for less than 1 week in 27, and more than 1 week in 18. The intensity is shown in Table III and the interval between the onset of the pain and the diagnosis of the carcinoma in Table IV. A detailed analysis of the pain for different locations of the neoplasm gave the following results: - Neoplasms in the hilar part of the left lung: deep and constrictive pain was felt in one or more of the following locations: retrosternal, parasternal or subscapular. The area of cutaneous hyperalgesia w,as wider than the area of the spontaneous pain. Frequently, hyperalgesia was also present in the left upper limbs. Muscular tenderness was almost always located within the pectoralis major. A slight muscular tenderness was sometimes found contr~ater~ly (Fig. 1, top). - Neoplasms in the hilar part of the right lung: pain was deep, constrictive, and poorly localized. Cutaneous hyperalgesia was frequently located near the sternum,
TABLE I HISTOLOGICAL
PATTERNS OF NEOPLASMS IN THE PATIENTS WITH PAIN
Small cell anaplastic carcinomas Epidermoid carcinomas Adenocarcinomas Adenomas (cylindroma) Not analyzed for technical reasons
8 26 14 1 23
TABLE II LOCATION OF THE NEOPLASMS Left bronchial tree Upper lobe Lower lobe Central (hilum)
31(48%) I 10 14
Right bronchial tree Upper lobe Middle and lower iobe Central (hilum)
34 (52%) 16 6 12
60 TABLE
III
INTENSITY Numerical
OF PAIN scale
Slight Moderate Severe Very severe
TABLE
Visual analogue
scale (cm)
No. of patients
0.6-2.5 1.0-5.8 7.3-7.8 9.3
23 23 10
IV
DURATION
OF PAIN AT THE TIME OF THE DIAGNOSIS No. of patients
More or less at the same time Up to 1 month previously More than 1 month previously
Fig. 1. Areas (bottom).
of spontaneous
37 23 5
pain in patients
with hilar cancer
of the left lung (top) and right
lung
61
Fig. 2. Areas of spontaneous pain in patients with cancer of the upper lobe (top) and lower lobe (bottom).
and
muscular tenderness within the pectoralis major on the same side (Fig. 1, bottom). - Neoplasms of the upper lobes: pain was referred to the anterior part of the chest, always supramammary, and to the acromial-deltoid region. Cutaneous hyperalgesia was present in the areas of spontaneous pain. Muscular tenderness was mainly located within the supinator (Fig. 2, top). - Neoplasms of the lower lobes: pain was more severe than in the other locations, sometimes deep and constrictive, sometimes stabbing and superficial, almost always specifically localized in the subscapular region, radiating in only a few cases as far as the lumbar region. A zone of cutaneous hyperalgesia, wider than the zone of spontaneous pain, was found in the left and right paravertebral areas and in the scapular area of the same side of the neoplasm. An area of muscular tenderness was almost always found in the parascapular region ipsilateraf to the neoplasm (Fig. 2, bottom).
Discussion
We believe that the number of examined subjects with primary lung neoplasms is sufficiently great to provide reliable information on pain at the moment of the diagnosis of the cancer.
62
The investigation carried out during the early stage of the neoplastic disease differentiates this work from other previous investigations: the incidence of pain in our subjects is indeed less than that observed in other studies [5-71. Pain is always accompanied by superficial hyperalgesia and muscular tenderness. An important finding is the correlation between the location of the neoplasm, the location of pain, and the characteristics of the sensory changes. This correlation may give a useful contribution to the early diagnosis of pulmonary neoplasms. It is, for example, interesting that in the early stage of the disease a cutaneous and deep hyperalgesia, in various locations of the chest, is always present on the side of the neoplasm. The correlation between numerical and visual analogue scales was good, but we believe that the visual analogue scales are preferable for their higher sensitivity. If the diagnosis of cancer of the lungs is made after the onset of pain referred only to the chest, pleural involvement should be considered, even if it is not clinically evident.
References 1 Huskisson, E.G., Measurement of pain, Lancet, ii (1974) 1127-1131. 2 Kanner, R.M., Martini, N. and Foley, K.M., Incidence of pain and other clinical manifestations of superior pulmonary sulcus (Pancoast) tumors. In: J.J. Bonica, V. Ventafridda and CA. Pagni (Eds.), Advances in Pain Research and Therapy; Vol. 4. Raven Press, New York, 1982, pp. 27-39. 3 Keele, K.D.. The pain chart, Lance& ii (1948) 6-8. 4 Scott, J. and Husk&on, E.C., Graphic representation of pain, Pain, 2 (1976) 175-184. 5 Teodori. U. e Galletti, R., I1 dolore nelle affezioni degti organi interni de1 torace. In: Atti de1 63O Congresso delta Societa Italiana di Medicina Interna, Pozzi. Rome, 1962, pp. 276-302. 6 Turnbuli, F., The nature of pain that may accompany cancer of the lung, Pain, 7 (1979) 371-375. 7 Ventafridda, V., Personal communication.
57
V-62
PAI 00943
Pain in Early Cancer of the Lungs Carlo Marino *, Massimo Zoppi **,l, Franc0 Morelli *, Umberto Buoncristiano *** and Elio Pagni *** * Department of Pneumologv, Local Sanifa~ Unir IO-D, Florence, ** Institute of Clinical Medicine, University of Florence, Florence, and * * * Department of Anesthesiology, Local Sanitaty Unit IO-H, Florence (Italy) (Received
17 July 1985, revised received 23 January
1986, accepted
6 February
1986)
Summary spread or 164 patients with early cancer of the lungs, i.e., without extrathoracic distant metastasis, were examined. Subjective and objective characteristics of the pain were studied. A correlation was found between the location of the neoplasm, the location of the pain and the characteristics of the sensory changes. These observations may be a useful contribution to the early diagnosis of primary carcinomas of the lungs.
Introduction Previous studies of our center on pain in patients with cancer of the lungs were carried out by Teodori and Galletti [5] who observed that pain was present in 80% of the patients with lung neoplasms. The pain was always referred to the thoracobrachial regions, with the following clinical patterns: (i) Early onset pain, referred to the side of the affected lung, prevalently the acromion, deltoid and scapular regions, accompanied by cutaneous hyperalgesia within the dermatomes T,-T, and by deep hyperalgesia of thoracic muscles such as the deltoid, pectoralis major and infraspinous. (ii) Late, intense, badly tolerated pain, diffusely affecting the chest and the shoulders, with pleuric, periosteal and nervous involvement.
’ Address correspondence to: Massimo Zoppi, Viale Morgagni, 50134 Florence, Italy.
0304-3959/86/$03.50
Institute
0 1986 Elsevier Science Publishers
of Clinical
Medicine,
B.V. (Biomedical
University
Division)
of Florence,
58
The research of Teodori and Galletti was carried out mainly on advanced tumors. and the onset of the pain was deduced from the history. A more recent study was limited to the description of the subjective location of the pain. Its intensity and accompanying signs were not investigated [6]. The present study was carried out on the patients with early and primary neoplasms of the lungs at the time of diagnosis. Patients in whom the diagnosis was made during previous periods of hospitalization or patients with advanced tumors such as extrathoracic spread, rib metastasis, brachial plexus and pleural involvement, were excluded. In this way it was possible to observe and describe the pain at its earliest objective and subjective manifestations.
Method
Over a period of 8 months, we examined 164 patients (143 males and 21 females, aged between 49 and 81 years) who were hospitalized in the Department of Pneumology. In all these patients the diagnosis of primary carcinoma of the lungs without extrathoracic spread or distant metastasis was made by means of standard examinations (roentgenograms, fiber optic bronchoscopy, sputum cytology, etc.). 80% of the patients underwent chest surgery. The location and histology of the neoplasm in all these patients was confirmed. The incidence of chest pain was observed. In the subjects with pain, location, intensity, quality, depth, onset and temporal pattern were recorded. The intensity of the pain was studied using the numerical scale, according to Keele [3], and a vertical visual analogue scale of 10 cm according to Huskisson [l] and Scott and Huskisson [4]. At the bottom of this scale the classification was ‘no pain’ (‘nessun dolore ‘), and at the top ‘pain as bad as it could be’ (‘il dolore pill forte immuginabile
‘).
In the patients with pain, the chest was examined: (i) By dragging a needle-point along the skin, at a constant pressure and speed. This stimulus was applied at many sites on the (anterior and posterior) chest, back and upper limbs, stroking in both upward and downward directions along the entire length. With this method it was possible to observe the presence and the location of cutaneous hyperalgesia; (ii) By applying various degrees of digital pressure to define the zones of muscular tenderness within the areas of spontaneous pain and of cutaneous hyperalgesia. The entire procedure was as follows: one of the investigators selected the patients with pain; another investigated the subjective and objective characteristics of the pain without knowing the location or histology of the neoplasm; and at the end of the investigation a third investigator correlated the clinical data with the sensory findings.
59
Results
Pain was present in 65 patients (59 males and 6 females: 40% of the total). The higher incidence of pain was found in the patients aged 65-69 years (20 subjects). In the patients with pain, the histological pattern is shown in Table I. The location of the neoplasm studied with roentgenograms is shown in Table II. The spontaneous pain was felt on the side of the neoplasm in 80% of the patients and was bilateral in the remaining 20%. It was continuous in 22 patients, showed remission for less than 1 week in 27, and more than 1 week in 18. The intensity is shown in Table III and the interval between the onset of the pain and the diagnosis of the carcinoma in Table IV. A detailed analysis of the pain for different locations of the neoplasm gave the following results: - Neoplasms in the hilar part of the left lung: deep and constrictive pain was felt in one or more of the following locations: retrosternal, parasternal or subscapular. The area of cutaneous hyperalgesia w,as wider than the area of the spontaneous pain. Frequently, hyperalgesia was also present in the left upper limbs. Muscular tenderness was almost always located within the pectoralis major. A slight muscular tenderness was sometimes found contr~ater~ly (Fig. 1, top). - Neoplasms in the hilar part of the right lung: pain was deep, constrictive, and poorly localized. Cutaneous hyperalgesia was frequently located near the sternum,
TABLE I HISTOLOGICAL
PATTERNS OF NEOPLASMS IN THE PATIENTS WITH PAIN
Small cell anaplastic carcinomas Epidermoid carcinomas Adenocarcinomas Adenomas (cylindroma) Not analyzed for technical reasons
8 26 14 1 23
TABLE II LOCATION OF THE NEOPLASMS Left bronchial tree Upper lobe Lower lobe Central (hilum)
31(48%) I 10 14
Right bronchial tree Upper lobe Middle and lower iobe Central (hilum)
34 (52%) 16 6 12
60 TABLE
III
INTENSITY Numerical
OF PAIN scale
Slight Moderate Severe Very severe
TABLE
Visual analogue
scale (cm)
No. of patients
0.6-2.5 1.0-5.8 7.3-7.8 9.3
23 23 10
IV
DURATION
OF PAIN AT THE TIME OF THE DIAGNOSIS No. of patients
More or less at the same time Up to 1 month previously More than 1 month previously
Fig. 1. Areas (bottom).
of spontaneous
37 23 5
pain in patients
with hilar cancer
of the left lung (top) and right
lung
61
Fig. 2. Areas of spontaneous pain in patients with cancer of the upper lobe (top) and lower lobe (bottom).
and
muscular tenderness within the pectoralis major on the same side (Fig. 1, bottom). - Neoplasms of the upper lobes: pain was referred to the anterior part of the chest, always supramammary, and to the acromial-deltoid region. Cutaneous hyperalgesia was present in the areas of spontaneous pain. Muscular tenderness was mainly located within the supinator (Fig. 2, top). - Neoplasms of the lower lobes: pain was more severe than in the other locations, sometimes deep and constrictive, sometimes stabbing and superficial, almost always specifically localized in the subscapular region, radiating in only a few cases as far as the lumbar region. A zone of cutaneous hyperalgesia, wider than the zone of spontaneous pain, was found in the left and right paravertebral areas and in the scapular area of the same side of the neoplasm. An area of muscular tenderness was almost always found in the parascapular region ipsilateraf to the neoplasm (Fig. 2, bottom).
Discussion
We believe that the number of examined subjects with primary lung neoplasms is sufficiently great to provide reliable information on pain at the moment of the diagnosis of the cancer.
62
The investigation carried out during the early stage of the neoplastic disease differentiates this work from other previous investigations: the incidence of pain in our subjects is indeed less than that observed in other studies [5-71. Pain is always accompanied by superficial hyperalgesia and muscular tenderness. An important finding is the correlation between the location of the neoplasm, the location of pain, and the characteristics of the sensory changes. This correlation may give a useful contribution to the early diagnosis of pulmonary neoplasms. It is, for example, interesting that in the early stage of the disease a cutaneous and deep hyperalgesia, in various locations of the chest, is always present on the side of the neoplasm. The correlation between numerical and visual analogue scales was good, but we believe that the visual analogue scales are preferable for their higher sensitivity. If the diagnosis of cancer of the lungs is made after the onset of pain referred only to the chest, pleural involvement should be considered, even if it is not clinically evident.
References 1 Huskisson, E.G., Measurement of pain, Lancet, ii (1974) 1127-1131. 2 Kanner, R.M., Martini, N. and Foley, K.M., Incidence of pain and other clinical manifestations of superior pulmonary sulcus (Pancoast) tumors. In: J.J. Bonica, V. Ventafridda and CA. Pagni (Eds.), Advances in Pain Research and Therapy; Vol. 4. Raven Press, New York, 1982, pp. 27-39. 3 Keele, K.D.. The pain chart, Lance& ii (1948) 6-8. 4 Scott, J. and Husk&on, E.C., Graphic representation of pain, Pain, 2 (1976) 175-184. 5 Teodori. U. e Galletti, R., I1 dolore nelle affezioni degti organi interni de1 torace. In: Atti de1 63O Congresso delta Societa Italiana di Medicina Interna, Pozzi. Rome, 1962, pp. 276-302. 6 Turnbuli, F., The nature of pain that may accompany cancer of the lung, Pain, 7 (1979) 371-375. 7 Ventafridda, V., Personal communication.