We have some more people joining us today, so welcome, welcome. And without further ado, so this is the AAPMR Cancer Rehab Tumor Board, as you all know. So welcome new and familiar faces and some people I might not know. We thought we would just get started by doing some brief introductions and then just a quick announcement and we'll dive right in. So doctors Fedou, Fricke, and Chang started this tumor board about two years ago, if I'm not mistaken, and I recently joined the leadership team. So my name is Eileen Slavin, I'm an attending at Cleveland Clinic, and I started their cancer rehab tumor, cancer rehab program, rather, about a year and a couple months ago. So I'm a native of Cleveland, I came back to start the program there. And despite the fact that it is super cold and snowy outside, it's otherwise been a really great job and Cleveland's a really good place to live and work. And shameless plug, if anyone needs a job next year, we're hiring. So I will put my info in the chat for you all. If anyone has questions or might be some medical students, residents, if you have questions about what we do, we can hopefully answer some of those maybe tonight in our discussion or you could always feel free to reach out, I'm available. So just wanted to ask too, if any attendings are signing on, we didn't have any messages in our Gmail for cases to bring up tonight. So if anybody has a case they'd like to present, they can put that in the chat for us too, just to give us an idea of how to allocate our time. And I think that's it for the moment. So we have Dr. Jin Lee, who is from the University of Pennsylvania, our cancer rehab fellow. So I will give her the floor and you can take it away. Hi. So my name is Jin and I'm the cancer rehab fellow from Penn. I'm not sure if I should be the one bringing up the slides or... Yeah, I can share them too. I have them. I also have them as well. So I'm not sure which... Okay, is that good? Yes. Thank you. Yeah, no problem. So this was an interesting case that I saw on my inpatient consults. And yeah, so I guess, next slide. So this is a 46-year-old male with history of grade two astrocytoma, initially diagnosed in 2011 with recurrence in 2015. Again, this was an inpatient consult who presented to our acute hospital for worsening of left sided weakness and altered mental status for about two weeks. And patient had a fall, patient was presenting from SNF. Other relevant surgical history includes patient had resection of the right frontal lesion in October of 2011, had subtotal resection of the right frontal non-enhancing lesion in 2015, with pathology showing the recurrence of the grade two astrocytoma. And also patient had some post-op complications, including infection, seizures. And had to get craniotomy for removal of intracranial abscess. And also in 2021, patient was reporting of severe headache and ended up getting resection of right temporal lesion, which was consistent with reactive brain parenchyma. Other treatment history for his cancer includes proton-based radiation treatment with concurrent temozolomide and six cycles of post-radiation temozolomide in 2015. Next slide, please. And other relevant history is that since 2021, patient has had repeated episodes of severe headaches, seizures, which slowly progressively worsened. Patient was managed by outpatient oncologists with anti-seizure medications, including Keppra, valproic acid. Also, patient was on Lyrica as well. And patient required some doses of, high dose of prednisone. Also, patient had prior multiple admissions with MRI of brain suggestive of SMART syndrome, which I will discuss later on during this presentation. And most recently, patient was admitted for about two months before with the MRI at the time, showing evidence of SMART syndrome. And patient was treated with pulse dose of steroids and was also added on some anti-seizure medications as well on discharge with the prednisone taper. Next slide, please. So for this admission, patient's initial presentation showed that he was mildly lethargic. Patient had left-sided weakness, upper extremity worse than the lower extremity, had some word finding difficulty with dysarthria. However, he didn't have any recent episodes of seizures. And patient has had mild intermittent headaches. Other workup that the primary team had done included infectious workup, which was negative. Urine drug study was negative. There was no acute bleed or anything like that on CT head. The MRI of the brain showed enhancement in the right temporal and right occipital lobe, which was consistent with recurrence of the SMART syndrome. Next slide. So this was my physical exam. Patient was alert and oriented times three. He was mildly agitated. However, he was able to follow commands, answer questions. And again, he had the mild dysarthria and weakness on the left side. In terms of his hospital course and treatment, patient was treated with high dose of IV steroids and then was started on prolonged steroid taper. The oncology and the neurology team decided to start on hyperbaric treatments for the SMART syndrome with total of 40 treatments. So this was a pretty long hospital stay for him. I think he stayed for about two months or so. And he also had other complications, just medical complications. Pneumonia, had some hypotension bradycardia leading to a very brief MICU stay due to initial altered mental status. They had some concern about his swallowing. So patient has had a PEG-2 placement done. However, by the time that I saw the patient that was improving on swallow study, and they were transitioning him over to PO. Next slide. So I wanted to talk more about the SMART syndrome, which is short for stroke-like migraine attacks after radiation therapy. Syndrome, this is a very, very rare syndrome. Based on literature, there has been maybe a hundred or some hundreds or so of the reported cases for the SMART syndrome. Based on review articles, this is thought to be reversible late to delayed onset for complication after brain radiation treatment. In terms of onset, or when you will see this after radiation treatment was very wide range. It could present maybe a year after, or even up to like 27 years or so after radiation treatment. For brain neoplasm, typically reported was that patients should recover in about 1.5 to 2.5 months. However, this is debatable, whether this condition is truly reversible, because there has been reports saying that a lot of these patients continue to have persistent deficits due to the SMART syndrome that they had. Typically, it's associated with more than 50 gray radiation dose to the brain. It can be either a whole brain radiation or focal brain radiation, and the pathophysiology is unclear at this time. It may be related to radiation-induced endovascular and trigeminal vascular system injury from the radiation, and typically patient presents with migraine-like headaches, focal neurologic deficits, potentially seizures. Typically, they recommend getting an MRI, and on the MRI, you will see unilateral cortical enhancement, more so on the posterior part of the brain. And there is no set guideline or like a standardized diagnostic criteria for this syndrome. However, I include a table there for diagnostic criteria for SMART syndrome that was suggested by one of the articles. However, this is not something that is like a set guideline in terms of the diagnosis for the syndrome. Next slide. So at this point, I kind of wanted to discuss about or ask if anyone has seen SMART syndrome at your hospitals. And in terms of treatment and management, it seems like there is also no clear guideline for this. And I was wondering what kind of management or treatment that you've seen at your hospital for the SMART syndrome. And I guess my additional question is, what are other late effects of radiation treatment to brain that we should keep in mind as well? Awesome. Thank you so much, Jin, for the presentation. I'd never heard of SMART syndrome before you brought this up for presentation tonight and reviewing it. So thank you for bringing this to our attention. Definitely really interesting and cool and something to keep on the differential. If you don't mind just pausing for one second before we go through your food for thought questions for discussion, because they're really good rhetorical questions to ask and to go through. I'm kind of wondering, specifically for your patient, just because it had been so many years since he was first diagnosed and he had been treated sort of on and off, right, for these lesions in two areas. Just kind of wondering, because I know, like you said, the SMART syndrome is supposed to be reversible. And I'm just wondering if he had multiple recurrences of the SMART syndrome, you know, did he get good recovery after those? And, you know, also, you know, kind of practically speaking, like rehabilitation wise, you know, just curious, you know, no right or wrong answers, but what were you able to do for him when you saw him on consults? Yeah, so I saw him for consults, actually, at the acute hospital setting. So it was not in like an inpatient, like a rehab hospital consult, for example. It was not an inpatient consult, per se, the patient ended up going back to SNF, where he came from. I believe he had an acute rehab hospital stay after, like, he got the surgery done for his cancer, but not necessarily after he was having these headaches. They were managing it more as an outpatient until he required admission. A couple of months ago when he was admitted, and then he was found to have SMART syndrome. But even before then, when the oncologists were getting the MRI and kind of doing the serial scans of his brain, they were noticing that he was having the enhancements there. So that's why he was kind of on and off the steroids. And it seems like he was getting some improvement of his headaches with that. But I'm trying to remember, I think the initial presentation when he had the left-sided weakness was after the last admission, which was a couple of months ago. But about two weeks before this hospitalization, he had a worsening of the weakness. OK, so he seemed to recover pretty well, you know, in between, you know, the occurrences. OK, yeah, interesting. Yeah, I was just, I just thought I would, you know, bring that up, right? Because from our perspective, we're foreseeing these patients ultimately. And I guess, you know, my bias, too, is that my practice is mostly outpatient. You know, if you're seeing someone in an outpatient setting, you're just trying to plan how to help them or, you know, how to sort of, you know, plot that course for the patient, you know, going forward or trying to, you know, catch somebody who has this, you know, maybe before they would get a brain biopsy or a really extensive workup. Yeah, it seems like the patient was recently discharged. And that was like after I made this PowerPoint slides. But he did complete the hyperbaric treatments. It seemed like his mental status did improve with that. So he was having less and less of the wax and waning of his cognition. However, he did not have much improvement in terms of his weakness. And it seems like from just from chart reviewing the oncology, the neurology team, they were thinking that maybe he will not really regain much of a function or in terms of like the strength since they didn't really see much benefit with the hyperbaric treatments. So I also that was that would be my next question as well. If anyone has seen SMART syndrome treated with hyperbarics at all. Yeah. Anyone else want to jump in and comment? This is, you know, really interesting. Yeah, firstly, I've never seen it in person. Although, ironically, when you described your case, it sounds so very suspiciously like what is happening to my friend's mom for the past two years after she was treated for her melanoma. So I'm actually very curious to read more about it. But specifically for your case, I was curious, because you mentioned specifically, there was no recent seizure activity or seizures noted. Was there any thought to potentially coming down off the anti-seizure meds because of his mental status? Because I was just curious if that was a compounding factor for him. If he wasn't having seizure activity? I don't know. Yeah, actually, that is a good thought. The neurology team didn't, they didn't really discuss about like, considering lowering down on the seizure medications. I think they were thinking that since he has been seizure free, since they have added on the additional medication since last admission, it will be safer to keep him on it. Because before then he did have seizure activities when he was admitted last admission. Yeah, but that is a good thought. Because he's on quite a lot of anti-seizure meds. So that could also affect the cognition, definitely. Yeah, it's interesting. I don't know how, because the syndrome is rare, like how much seizures were to happen, you know, and it may, considering the location of the enhancement, it makes sense. But yeah, it's just something interesting. Yeah, definitely. And I think seizure is one of the common symptoms that come with the SMART syndrome. Yeah. I guess it would make sense to have a lot of those on there then. But yeah, definitely. But I think the cognition did improve with the hyperbaric treatments though from chart checking. Cool. Interesting. Well, I'll admit I've never seen this either. Obviously, it's super rare. One question I had kind of on the same vein is, did neurology repeat during the most recent admission, any like video EEG or anything to just confirm he wasn't having, you know, subclinical seizures? I do have a typical meningioma patient, which is a very different thing. But she just has basically awful recurrent seizures. And she pretty much lives in a constant state of Todd's paralysis. So she always like starts to recover and starts to get almost there. And then she just seizes and it's weak again. She just never has gotten kind of out of that loop. And they've done a bunch of different things for her to try to get it. But it's been a real challenge to improve her weakness because although her tumor isn't directly causing motor ship invasion, causing the weakness, it's this constant just seizure activity. So I'm curious if they actually like are continuing to look into that. Yeah, they actually did get the EEG, the LMT, the long-term like EEG monitoring. So they did that and that did not show any like significance in terms of seizure activity. So they did rule that out. So there's a message from the chat. I don't know if you can see this, Jen. It says, was the patient treated with verapamil? Actually, oh, I'm not sure. I'm not seeing that. But no, no, patient was not treated on that. And that's interesting because the review article, I did include that reference into the PowerPoint, but the review article that I was basing a lot of my, I guess, reading on this didn't mention about use of like calcium channel blockers in terms of managing like headaches. So it seems like from that review article, a lot of the treatment or management of the SMART syndrome is targeting the symptom management and for headaches, they did recommend trial of like calcium channel blockers. And also they mentioned about, you know, treating the seizure with the seizure medications, steroid pulse therapy as well, and managing blood pressure. So it's a lot of just symptom management. Yeah. I mentioned, I asked about it and so I missed the first few minutes because in, I've only seen this once in our patient who was having like migraines and was on seizure prophylaxis. But I, in talking to neurology, I think for verapamil, the calcium channel, calcium channel blocker, the role of it, even though the patient was not like hypertensive was more so for a vasculature effect. Cause I think there was, I think that's the thought of like how these symptoms are mediated. So using it as a vasodilator, as long as it was within a safe range of motion, safe blood pressure range, like it wasn't used for hypertension, but more so as the calcium channel blocker effect. And they were on it for a long time, I think still like a year past symptom onset. And I wonder if it's more so for that vasculature, like vasodilation effect, if there's any role at other symptoms like cognition or yeah. Yeah. I think, I think that would make sense. I think one of, although the pathophysiology for the SMART syndrome is not completely understood, there is they think that there is a component of the vascular injury from radiation. So I think, you know, use of calcium channel blockers does make sense. Maybe there might be some component of vasospasms or whatnot, a brain that could be causing or contributing to the SMART syndrome. But no, they did not talk about that actually. They did not suggest, it was unclear for me why they wanted to try the hyperbaric treatments. There was no kind of explanations in terms of like why they were heading in that direction versus using medications. But that is a good thought. I'm not sure why they didn't try the calcium channel blockers. There's also some, you know, interesting thought too, when I was reading about, you know, some of the articles I was going through, and one was looking at prognostic indicators and just trying to, you know, see if there were any, you know, statistically significant differences between our, you know, it was a pretty small sample size. But anyway, it's just interesting because a lot of these patients will get steroids, you know, for having a primary brain tumor or even a metastatic lesion, right, as a part of their treatment or when they have other symptoms. when they have other symptoms that pop up, you know, after radiation or surgery. And, you know, one of the articles that I saw, like I said, really small sample size, like, you know, preliminary data, but it was suggesting that that was actually a poor prognostic indicator. So I don't know if those patients were just maybe sicker at baseline. I'm not really sure because it didn't really go into the specifics of their pathology and, you know, maybe some other characteristics that, you know, would have been interesting to know. But I thought that was so interesting because so many patients end up on steroids, you know, in these scenarios. So I was like, oh, that's weird. You know, you'd think it would help, but, you know, it didn't seem to help with symptoms. So, you know, just thought. Yeah, that's interesting. A couple of case reports I've read on this. They also were using the steroid medications mostly. And it seems like most people do pretty well with the steroid medications. I'm not sure in terms of having, like, worse outcomes from use of that. But, yeah. Yeah. It sounds like from whatever you described, it sounds like they're basically just treating it like a radiation necrosis and trying to see if that improves things. Yeah. Have you seen patients with, like, radiation necrosis who did improve with the hyperbaric treatments? I haven't seen them, like, on consults or whatnot yet in terms of, like, radiation necrosis. Not necessarily a SMART syndrome, but I was wondering if you've seen hyperbarics used. I've seen it for post-mastectomy pain. You know, it was kind of like a last ditch effort. I had a patient, you know, come to me who had used or had been through hyperbaric oxygen therapy. I ended up doing Botox for pectoralis spasms and pain for her too, you know, on the side of her cancer. But, no. I mean, I've seen, you know, on inpatient consults, you know, for dysborex, I've seen patients who have had radiation necrosis because they have to get a biopsy to make sure there's no recurrence. And the imaging is unclear, and so it's, you know, just decided that they should have the biopsy. But, you know, most of these patients go to a SNF, go to acute rehab, and then, you know, follow up outpatient. So I guess I never maybe really, you know, followed through in the paper trail, but not, you know, not to my knowledge. I've seen a patient with the history, not like during it, but just catching up with his history that had neck cancer, and he ended up having some necrosis. And they did use hyperbaric oxygen treatment to treat it, but he ended up still needing a maxillectomy and, like, removal of some of that necrosis, necrotic tissue, unfortunately. So I don't know how useful it was, but it was just part of, like, his very long, complicated history. And great presentation, Jen. Oh, thank you. Yeah, I think I've seen it a couple times. I think the response has been variable. I would say drastic. I think that some people see benefit. It just depends on, you know, who it is and how safe it is to basically put them into the tank, and if they can get it covered. So I guess I have a question in terms of just differentials. So for patients who had radiation treatment to the brain, other than ruling out like tumor recurrence, brain metastases, I guess the Smart Syndrome and like radiation necrosis, are there other differentials that are more common that I should look out for? So just like in a patient with new weakness or whatnot? Yes, or headaches, I guess. So like other than like, you know, new brain bleed and infection stuff like that, are there anything that's more like radiation induced type of side effects I should look out for? No, I mean, you can also think of stroke and things that happen in general to people. But yeah, I mean, I don't think radiation necrosis in general has like a very clean symptom pattern, at least in my experience. And I honestly, I think if I had seen this patient, the first thing I would be concerned about would be recurrence or stroke. Or I guess, kind of how the other patient was described by Dr. Faddu, of that like kind of weird Tot's paralysis, kind of weird scenario. You can even think of something like that. But for this one, it's unique. I certainly would have had to do some research before I would have infected with Smart Syndrome, seeing as I did not know much about it. So I think you probably were thinking a lot of the logical things. Thank you. That sounds like a good differential. That makes the most sense, especially focusing on the brain. I guess what's also possible is maybe there's lesions also in the spinal cord area that could be concurrent, just thinking a little bit out of the box, like maybe everything goes to brain, but maybe there's also something happening in the spine contributing to the weakness. Yeah, I would say I agree. I have seen drop nets to the spine and spinal cord before, but in my experience, it's, you know, more often than not, the differential is pretty much scan them and it's usually basogenic edema, radiation necrosis, where they're just getting neurologic changes without really an image finding correlate, but usually there'd be some scarring and kind of gliosis in that area or occurrence. Occasionally, I have seen sometimes people, their neurologic symptoms and their functional decline precludes their image change with recurrence, but seeing people kind of start to have changes, start to decline, we scan them, it's normal, they get a scan in a relatively short time later, like a month or two later, and now they have recurrence as things just kind of continue to progress. I've seen that before too, but usually there's not anything crazy magic. It's usually edema of recurrence or necrosis in my experience, or like a stroke or something. I was already said something that's just completely different, but especially if it's in the area where they already had symptoms, it's usually kind of one of those three in my experience. I definitely think that's a good thought about the, if it's not showing up now, it's still good to be there. Just give it a little bit of time. That's definitely been the case, not only for brain, but I've had other times when I'm like, man, this screams cancer. I'm relieved that the imaging doesn't show it, but I'm nervous that if this scan is done shortly thereafter, it will. I think there's also a good thought about like the weakness and the steroid and considering not only are they taking steroids, but what dosage. So during a journal article, journal club that I did actually with Dr. Power, we're looking at steroids that are usually received with patients with like graft versus host disease or inpatients with central nervous system tumors or whatnot, or growths and neoplasms in any case. I think it's like 40 milligrams per day or more and that it was seen that they would have steroid induced myopathy and especially the longer term that they've been on the steroids and especially if it was over 40 milligrams that they would have myopathy, but that's usually I think not sudden, right? It's slowly progressive weakness in the muscles rather than a paralysis or a hemiparesis. I think that's a good, good point. Not only focus the differential on the central, but it could be a peripheral cause as well. So yeah, I always encourage people, I always encourage people to like use your skills as a physiatrist, strictly exam skills. I had a patient once that I got a bit of some tips with neuro-oncology, not tips, but I had to reach out and we had a conversation about this patient because he was like, oh, this patient keeps having steroid myopathy, we've got to get off these steroids. So he kept taking away this guy's steroids and he had brain meds and he kept getting worse. Every time I went off the steroids, he would just get functionally worse. He would go from like pretty basically functional at like a Walker level and able to like stand and cook to being like bed bound. And he kept the neuro-oncology saying steroid myopathy, steroid myopathy. I later found out that he published a review article on steroid myopathy, so it made way more sense why he was so obsessed with steroid myopathy. But I was like, he keeps getting hemiparetic when we go down off the steroids. That's not steroid myopathy and he's hemiparetic in the areas of sleep, he's getting vasogenic edema that we need to control. So just you have skills and even sometimes when you think there's other people that kind of maybe should be a little more aware of this, use them because sometimes you can tease things out. And the other thing too is I was like, if he's getting a little weak from steroids, who cares? He's like a million times more functional. We were getting kind of not seeing the forks from the trees kind of thing. So yeah, don't be afraid to kind of dig in and use your skills there because like I said, not everybody has the blend of the neuro and the neuromuscular and musculoskeletal training that we have that can kind of put some of these more complicated packages together. Also another tidbit is I've seen this a handful of times, but sometimes when you see these people that have multiple recurrent admissions and they keep blasting them with steroids, nobody's paying attention that they're adrenally insufficient and they come in with some kind of new insult. Nobody's actually stress dosing them. So they're not paying attention and saying that they're actually an adrenal insufficiency and that can also cause some weakness and other things like that. So just something to be aware of and to be mindful of. Yeah. Yeah. Thank you. Yeah. Another thing I was thinking about too, just to switch gears a little bit, but I've seen this is controversial in and of itself, but I've seen some patients, especially who get the, what is it called? The whole brain irradiation. Like if you have small cell lung cancer, right. To prophylactically prevent, you know, lesions in the brain. Some of those patients are treated with memantine for a certain amount of time. So I don't know when I was going through your presentation, I thought like, oh, I wonder if that was ever thought about as something possibly to help. I mean, I know you think of anti-epileptics and steroids and calcium channel blockers and some of the usual suspects to treat. But I was just thinking something like memantine, especially for cognitive issues too, that would be interesting to know. I didn't look that up in PubMed myself, but I was just like, oh, well, I've seen that for other patients who have brain radiation too. I was like, hmm, I wonder if that's something. Yeah. Yeah. I've seen that in other patients as well. And yeah, I'm not sure, maybe trying to remember if he was on it as one point. When I was seeing him in the inpatient, he wasn't on that medication. But I'm thinking, you know, since his radiation was way back in 2015, it's been a while. Yeah. He could have been on it at one point and maybe he had improvement and he came off of it. But that is also a good thought as well. Yeah. Yeah. Even for like more acute cases. I mean, he had, you know, smart syndrome a couple of times. But even for like someone, you know, presenting for the first time, that would be interesting. Yeah. To think about for sure. I was telling Eileen that I was looking into Memantine recently, actually, for one of my patients, because he was about to face brain radiation. Then I started looking up PubMed and I was like, oh, it's not really clear. You know, some say it's underutilized. Some say there's a little bit of benefit in preventing cognitive decline. And so then I started asking some of our cancer rehab peers and seem kind of mixed and not so favorable of what they've seen and practice of it actually being helpful. I mean, it's you're preventing a negative thing. It's probably something kind of hard to notice if cognitive decline is happening slower versus faster. But then I asked my radiation oncology colleagues as well. And one of them said that only for whole brain radiation treatment, that they would always do Memantine. And so it seems like radiation oncology might be pretty different in their practices. Some might do it as needed. Some might do everybody. And so that might be good to connect. Or this, you know, could be a good case over which to connect with radiation oncology and just to understand what their practice is and why what they think of the evidence, because ultimately it's treating the sequelae of their radiation. Any other comments or questions about this case? It's been a really good discussion so far. I've learned a lot. Great. Well, awesome. Thank you so much, Shin, for presenting tonight. Really appreciate it. And thanks for making me aware of this for the future. It's a really good food for thought. Thank you. Thank you so much for all the comments too. Yeah, bravo. Awesome. And Jess, I know that you had a case. I don't know if anyone else, I was trying to stop this chat just to make sure I didn't miss anything, but I know you had a case and maybe someone else will have an informal case if you wanted to jump right in. Yeah, I know I'm so eager to share this case with everyone, especially eyeing the MedStar folk that are on here for any input on this post-mastectomy syndrome case. So this is a 57-year-old female. She had right breast cancer. She went through the whole thing with a mastectomy, lymph node dissection, radiation to the chest wall. This is all four to five years ago. So she's not on cancer treatment anymore, but she has a lot of diffuse neuropathic pain that we've been wrestling with for many months now. It's been really hard to get her to show up to appointments because of multiple psychosocial, other medical comorbidities as well. But let me see if I can share my screen to draw the, let's see, share the correct screen here. Can you see that? This is just Google images of dermatomes. So I have to click share. Now, can you see it? Yeah, we can. Yep. Okay. All right. So I was going to plan, the short of it, I was going to plan an injection of erector spinae plane block for the first time, but I'd really love to hear people's experience with that. But the reason I was thinking that was because her, what's a good picture here? Her pain is roughly T2 to T7, maybe T8-ish. It's below the, as low as below the breast tissue by a couple feet abreast and some involvement of the proximal menial arm. And I thought at first it was just primarily in the lateral aspect and inferior, like horizontally under the breast, that's the most sensitive. And then I re-examined her after a long time because so much has happened in trying to plan an injection and trying to get her in. Um, she also has a lot of pain in the same posterior wide swath of region. And she was so allogeneic that with palpation to maybe just under the dermis, she's wincing and like about to cry in pain throughout this entire area. And so I'm concerned even though ultrasound probe pressure, she won't be able to tolerate. She also has vocal nodular, palpable nodular pain underneath the breast, kind of in a linear fashion. And she's actually had that biopsy way back in January before, and it showed fibro adipose tissue and focal fat necrosis. And so with all of this pain, she's been only able to actively forward flex and abduct about less than 90 degrees for a long time, obviously impacting ADLs, IDLs, mental health, spirituality, like significantly. Um, we've been trying to do injections for a long time, but all those complicating factors keep getting in the way. Also has arm lymphedema, same arm lymphedema, carpal tunnel syndrome. And so at first she was just lateral pain is the most significant and interior. So I was thinking serratus plane block. Then I found the posterior pain and I was going to change it to erector spinae block this coming week actually. Um, and I'm curious to hear people's experience on that. I did start her on deloxitine 60 milligrams daily, which she said it helps her breathe better. So I was thinking that we'd start with the block and then potentially increase the deloxitine afterwards, if that's not helpful, but just curious, like what else would you guys think about? There's been thoughts about maybe erector spinae block under floral or thoracic epidural. Um, but yeah, we'd love to hear thoughts if anyone's seen this before. Um, it sounds very complicated. I don't know if I've ever had somebody with like that degree of allodynia that you're describing, like you mentioned some social issues too. Does she have like psych issues? Yeah. It's she said it's all related to this change in function. Yeah. It is and quote unquote brain tumor. And that's not an MRI. And we haven't gotten a brain MRI for like half a year for whatever complicated reason. Yeah. I think that, um, the way you're approaching it is excellent. Um, I do think if you have access to pain psych, uh, in addition to what you're doing it and she's open to it, it might be helpful. Um, yeah, like initially I would have thought, Hey, Serena's playing, but then you described the full extent and the erector spinae seems like an excellent idea. I can personally say I have not done that. My colleague, Dr. Rosofsky started, um, on a few times. Um, but I'm always like slightly tentative when I have not done something soon. Like first I'm always like, Oh, um, so I usually just like punted to him because I'm a big chicken. Um, but, um, it, it is seemingly straightforward. Like I observed him do it and I'm sure that you will do it excellently. And I do think that, um, you could do it under fluoro. You could do it under ultrasound. And I remember the paper that kind of, um, was talking about the technique that came out a couple of years ago. That was, um, kind of nice and I had pretty good pictures and I can't remember what, who, um, talked about it. The only thing I would say about what you said is I personally don't usually go up above 60 for duloxetine for pain. Um, I haven't seen too much success personally. And with the data, um, granted, you know, you might have some success if there's anxiety or some of the other components. Um, but that would just be the only thing that what you described that I'd be like, Oh, I might not do that. But everything else sounded very well thought. Yeah. So I, I was trained with 60 max, and then I was talking to my colleague that was paying fellowship train and they go up to like 90 or 120 sometimes. And so that's where that thought of 90 came about. But, um, you know, should the lidocaine patch works amazing for her Ed menthol helps kind of, um, well, yeah, I would do that before you inject her so that you don't have already doing that. Yeah. Okay. She's already doing that. So I'm, but she's still in severe debilitating pain. So I'm like, okay, but what next? Yeah. But I mean, like even before your procedure, make sure she does something like that before, because you're worried about the ultrasound probe, like, you know, get her nice, light it up before you, uh, inflict upon her the procedure. Right. Which brief, right. I've been her perspective. It would be inflicting, but no, no, no. It will do a wonderful job, but yeah. Oh, no, I'm saying with, you know, all the other psychosocial aspects. Um, but I'm curious, do you guys ever prescribe lidocaine like for patient to self apply before the visit? Cause it can take 30 to 60 minutes to kick in. I don't, because I don't find it to be super helpful except for like peace of mind. I mean, I also occasionally do it for like two of my patients that we inject facial muscles with toxin, but I've done it for other people. And they're like, yeah, I didn't do anything like, and this is 30 minutes before. So in general, I'm just like, meh. So then cold spray, cold pack, cold spray, hardcore cold spray. Um, cause if it's temporary, it's hard. I know. I usually use it just for injection site. That's why this was new to me. I'm like, I don't know. She might have a hard time with just the ultrasound probe. She was wearing a sports bra, which maybe she just gets accommodates to the pain after a while. Could be. I think Dr. Faddu or someone else was just about to pop in with something. Somebody else was going to sit up. I have just one potential thought is, um, I've seen a lot of people that have pain along the scapular border area, um, that sometimes have a really hard time describing. It can also send us to be a very tender place for them that have just scapular thoracic bursitis because of the biomechanical chest wall, that dysfunction that happens from the tightness of the pec minor affecting the scapular thoracic motion. And, um, often it can present as a pain that kind of shoots through the chest towards the shoulder blade. It's also the most mastectomy is the highest risk factor for it. Um, in one study, and it can actually mimic chest pain. So sometimes patients feel the pain of chest, but they don't think about it's actually kind of moving court, that shoulder blade. So, um, she could potentially be having something like that too. And that's a much easier injection. In my experience, you basically just slap the ultrasound probe right over the needle scapular border and side needle, just parallel to the ribs underneath, and then just inject there. And I will say for people that have this, the injection is usually like a magic bullet. It's usually resolve a hundred percent of that pain. So just something else to think about, I guess, that might be a little simpler for her, especially if she's already a little bit tense about the thing. It's also probably a little bit of a quicker, easier injection, smaller gauge needle. Um, so that's just something that I've had a lot of success with for people that have that. Um, and it also makes a lot more sense from like a post-mastectomy like biomechanics standpoint. Okay. I totally missed a key word. Was it dorsal scapular? No, it's a scapulothoracic bursitis. Okay. And you see it radiate interiorly sometimes. No, it actually presents a chest pain often. Um, so it's actually a chest pain mimic, and it can radiate through the chest towards the shoulder blade. Usually if they, I'll ask them that question. If they have that, then I'm like, and I just do a scapulothoracic bursitis injection. It completely resolves it. Oh, thank you. Yeah. Especially people that have really, really tight pecs, really, really tight pecs, minor in particular. Um, like I said, it just yanks down on that, on the forecourt and affects the scapulothoracic motion. I definitely see that at times as well. I don't know if, um, to the degree that it like mimics type chest pain, but definitely, um, with some radiation to the front. So it's an excellent thought. Does that come with aledinia? Cause this aledinia is in severe. Not my experience. Yeah, I would say no, but I do have a couple of patients that just kind of have probably like nociplastic pain where they just have, uh, you know, kind of pain sensation. They tend to have a lot of psychosocial factors involved. You know, they're also kind of usually tender along other myofascial points and stuff like that. So, um, it just depends. I mean, some of these are a little harder to tease out and basically just have a little bit of those, like kind of chronic pain characteristics. Um, but I kind of go with kind of what makes sense and kind of what's safest, and then just kind of go through an organized process because often the patient will have potentially more than one thing. I don't think the serratus plane block is a bad idea either, just because I'm a fan of, if, if it makes sense to do, there's also that diagnostic component of the nerve block is shutting down nerves. So it also gives you a lot more information to move forward with. And I'll just, I'll like talk about that with patients. And usually that's, um, especially if it's a much more straightforward procedure, then it's something that you can just start to kind of eliminate by process. Yeah, because I was thinking that the serratus plane hits the area of the most pain, which is the lateral and like inferior breast region. Um, and then maybe like, if these, all the ones we've mentioned so far aren't working, maybe go for like glenohumeral or some of the usual shoulder, if it's just radiated and like diffused like that far. Um, I think I saw Jessica Casey, nodding her head. I'm sorry. It's like an aggressive nod over here. Tell me more about your nod. All right. So I was thinking because of the aledinia, I feel like there's a central sensitization like factor as like previously kind of said that it's more, um, there's like a psychological piece, right. That it's just like, not even just peripheral, but no, it's connected and you just have this like ongoing cycle of just like the pain being worse and, and, and, uh, long-term potentiation that occurs with that. So I think, uh, CBT is the best thing for it. So if she does get that psychological piece with the cognitive behavioral therapy, it's actually there, there are studies that show that that helps with PNPS. Um, so I think if she has that, that'll be a great tool for her to have during the procedures because then she can use those relaxing techniques and those techniques that she learns to do it during the procedure. And then also, um, I was wondering as far as the, um, the pain, if it's burning, like maybe she could try a capsaicin cream and like, but just be religious about it, you know, and like putting it on and then that'll help the self massage and kind of desensitize also while she's massaging it, which is nice, but, um, maybe capsaicin cream. And then if the capsaicin cream works, maybe Q-Tensa, I don't know how much Q-Tensa is charged though. Cause it's covered when people have diabetic neuropathy and you could put it over your, um, your feet, but so I don't know how much it would cost, but if the capsaicin is, I don't know, working that, that might also be an option for her. Maybe like those patches. Yeah, I was thinking capsaicin, but maybe this is a question for everyone is cause like how helpful is capsaicin in your experience? Cause I haven't used it that much before and over the counter capsaicin, right. Versus Q-Tensa. Um, Hannah had a question too. I think you raised your hand. Oh, yes, but I don't have a great answer for the capsaicin. I've tried for patients with some allodynia, especially if they want to avoid oral medications, but I would say efficacy is just person to person. Um, but I was just going to ditto what Mike said. Um, and I think if you're going for any block, especially when patients have diffuse areas of pain, I think it's, it's critical to like set the expectation of like the expected, um, outcome of what you're trying to block, especially if this posterior pain is more secondary or new and, um, versus a serratus. Um, but I agree that there's like a value for, um, as a diagnostic intervention as well. Thank you, Hannah. Oh, that brings to mind. I just want to comment on what Kat was saying about not starting these blocks for the first time. I'm having anesthesia who's done this before support me. So that's, that's where my confidence comes from. And they say it's way safer than many of the other blocks. Well, support or no support. You'll, you'll kill it. You've got this. I can't go wrong with someone supervising me. I think. Yeah. Any other thoughts? Um, I mean, we continue, we can continue, um, after nine, but I'm also mindful that, um, it's late on East coast time. So if anyone has to leave, um, you know, after nine, that's, um, perfectly okay and acceptable. We have lots of things to do. Um, and then just as a reminder to do the, um, CME on the online learning portal, just to make sure you get your credit, but we do have another minute or two, if anyone has any other comments, I think, you know, honestly, I've had one or two patients this year, you know, in the mix that I've had post mastectomy pain, and it's been really hard to treat. And the one patient I have in particular also has, um, you know, really, really big psychosocial, you know, burden, um, does not have family support really at all, um, is a little bit estranged from some friends and some other community activities. And so I had tried a serratus plane block on her, um, and it didn't work very well. She was really reluctant to try medications or to try, you know, anything else really for that matter. And so, um, this was also at the beginning of, you know, starting as an attending and I'm like, oh my gosh, you know, I feel like I'm already stuck. What's going on? Um, super nice patient. I just, you know, felt like I failed because I couldn't help her when, um, you know, I think that's like an important piece, at least like for me, like for her specific scenario, you know, we do our best to help people, but sometimes we can't help everyone. Um, and that was an important piece to learn. Um, she did get an intercostal nerve block with pain management that also didn't help. I'm not surprised to be honest, just, um, given how much she had going on, um, you know, in her life, but, um, I'm with you there, Jess, it's, it can be hard, right? It can be really, really hard to treat certain kinds of pain. Um, and post-mastectomy pain is tricky. There's a lot going on. So yeah, thanks for, um, for bringing that up. That's a really good case. Thanks everyone for your help. Yeah. Um, does anybody else have any last-minute comments, questions? I put my info in the chat as promised. If anyone needs a job next year, shameless plug, um, or just wants more information or, um, you know, if you're a medical student or a resident on the call, um, and want to reach out and get more info, please feel free to reach out. But I think that's a wrap. All right. Thank you all so much. Have a great night. Okay.

AAPMR

Cancer Rehab

SMART syndrome

astrocytoma

hyperbaric treatments

calcium channel blockers

post-mastectomy pain

interdisciplinary collaboration

patient-centered care