Acute Pain

Acute pain after surgery or radiation therapy can be successfully treated with conventional algorithms for acute postoperative pain. Nerves are frequently severed, compressed, or stretched during tumor resections, making it possible for neuropathic pain to be a major factor during the postoperative period. Adjuvant analgesics should be initiated when a neurogenic contribution is suspected. As with all postoperative pain that impedes function, aggressive opioid-based and antiinflammatory analgesics should be considered. Acute pain control allows movement, minimized needless deconditioning, and enhances participation in the rehabilitation process.

Acute pain can also complicate the administration of chemotherapy, hormonal therapy, or irradiation. Most of the associated pain syndromes are transient but may produce intense discomfort warranting aggressive analgesia. Acute pain syndromes associated with cancer therapy include paclitaxel-related arthralgias and myalgias, bisphosphonate-related bone pain, radiation mucositis, steroid pseudorheumatism (following withdrawal of corticosteroids), intravesicular BCG–induced cystitis, hepatic artery infusion pain, bone pain associated with colony-stimulating factor (CSF) and granulocyte macrophage CSF administration, and radiopharmaceutical-induced pain.

Chronic Pain

Chronic cancer-related pain can arise from visceral or neural structures but is most commonly associated with bone metastases. Bone metastases occur in 60% to 84% of patients with solid tumors. Pain intensity does not correlate with the number, size, or location of bone metastases, nor with tumor type and 25% of patients with bone metastases report no pain. Bone pain is particularly relevant to physiatrists because moving or loading affected structures can precipitate severe pain. As mentioned earlier, bone pain responds well to local irradiation.

Nonsteroidal Antiinflammatory Drugs for Bone Pain

Nonsteroidal antiinflammatory drugs (NSAIDs) are considered first-line therapy for bone pain, and a trial is warranted unless contraindicated. Cyclooxygenase (COX) nonselective inhibitors offer comparable or greater pain relief than COX-2 inhibitors but a less desirable toxicity profile. Choline magnesium trisalicylate causes less inhibition of platelet aggregation than other COX nonselective inhibitors but did not statistically outperform placebo when trialed in cancer-related bone pain. COX nonselective inhibitors with less desirable toxicity profiles have proven more effective. Several placebo-controlled, randomized trials found that ketoprofen reduced cancer pain to a greater extent than either codeine or morphine. NSAID doses for bone pain are no different from NSAIDs at antiinflammatory doses for pain of alternative etiologies.

Adjuvant for Bone Pain

Adjuvant analgesics can augment NSAID-related control of bone pain. Corticosteroids effectively relieve bone pain. Their toxicity profile (edema, bone demineralization, immunosuppression, and myopathies) is problematic and must be considered in assessing the risk-to-benefit ratio of steroid therapy, particularly with chronic administration. Parenteral bisphosphonates are also effective. Denosumab, a recently introduced monoclonal antibody therapy, was found in a metaanalysis to be as or more effective than bisphosphonates in controlling pain from bone metastases. Use of calcitonin for bone pain is discouraged because of weak supportive evidence and rapid tachyphylaxis.

Opioids for General Cancer Pain

As mentioned previously, opioid-based pharmacotherapy is the current standard of care for the management of moderate to severe cancer pain, irrespective of its origin. Opioid use should be restricted to pure mu-receptor agonists. Those most commonly used in cancer pain management include morphine, hydromorphone, oxycodone, oxymorphone, fentanyl, and methadone.

The dominant paradigm for opioid administration has a well-established track record and has been reiterated by many experts in the field with few changes over the past decades. Recognizing that most patients experience constant, baseline pain punctuated by transient or incident pain, the combined use of normal and sustained-release or continuous-release opioid preparations is recommended. To rapidly estimate initial dose requirements, patients should be provided liberal access to a normal-release opioid formulation. Once their use has stabilized (this may take a day with patient-controlled analgesia pumps, or up to a week with oral dosing), mean daily or hourly consumption can be calculated and an oral or transdermal sustained-release preparation initiated. The ongoing dose titration should be driven by patients’ use of supplemental normal-release, “rescue doses.” Typically, rescue doses are 10% to 15% of the total daily dose.

Several practices will increase the likelihood of a successful opioid trial. First, anticipate side effects, particularly constipation and nausea, and address them proactively. Second, in the absence of dose-limiting side effects, resist the urge to switch or add additional opioids when a single mu-receptor agonist initially fails to control pain. Current recommendations urge a single agent dosing to “effect or side effect” and each agent should be adequately trialed. Third, remain vigilant for opioid-induced hyperalgesia and alterations in patients’ capacity to absorb, metabolize, or eliminate opioids in the face of progressive cancer.

Opioid Conversion

Significant intraindividual variations in response to different opioids have long been recognized. An alternative opioid should be considered when an “adequate” trial of a particular agent has failed to control pain, or has caused refractory side effects. Opioid dose conversion requires calculation of the equianalgesic dose of the novel agent ( Table 29-2 ) and reduction by 50% for incomplete cross-tolerance. Incomplete cross-tolerance describes the property of opioids to induce analgesic tolerance with sustained high-dose exposure. Tolerance is usually considerably lower to a novel agent. For this reason, patients often experience greater sedation and needless side effects when exposed to 100% of the equianalgesic dose. Opioid conversions are based on estimated dose equivalencies. Providing patients with liberal access to rescue doses is crucial during the conversion period to avoid pain crises.

Invasive and Intraspinal Analgesic Approaches

As mentioned previously, permanent ablation of central afferent tracts becomes tenable in the context of advanced cancer, and has been used with considerable success. More discrete neural blockade effectively reduces pain transmitted by one or several adjacent peripheral nerves. Intercostal, paravertebral, genitofemoral, ilioinguinal, and trigeminal nerve blocks can afford dramatic relief and reduce analgesic requirements. Nociceptive impulses of visceral origin can be blocked by ablation of sympathetic ganglia. Celiac plexus blockade affords excellent relief of visceral cancer pain. Intraspinal opioid administration can reduce dose requirements and associated side effects. For patients experiencing dose-limiting side effects, im­­plantable intrathecal opioid delivery systems may achieve a superior analgesia to side effect profile.

Bone Metastases

Bone metastases are highly prevalent because bone is the most common site of metastatic spread, and osseous lesions complicate the most frequently occurring cancers: lung, breast, and prostate. Thyroid cancer, lymphoma, renal cell carcinoma, myeloma, and melanoma also commonly spread to bone. Between 60% and 84% of patients with solid tumors will develop bone metastases.

Of greatest physiatric concern are lesions involving the spine and long bones. These structures are crucial for weight-bearing and mobility, and are most prone to fracture. Bone metastases are managed with medications, radiopharmaceuticals, orthotics, radiation therapy, or surgical stabilization. The choice of intervention(s) will depend on lesion location, degree of associated pain, presence or risk of fracture, radiation responsiveness, and related neurologic compromise. The overall clinical context (e.g., prognosis, severity of medical comorbidities, and operative risk) must also be taken into consideration. Most patients with nonfractured bony lesions can be treated nonoperatively through the use of systemic therapy and radiation.

Bisphosphonates are the primary medications used to manage bone metastases. Use of these agents reduces the spread and progression of bone metastases, in addition to relieving associated pain. Use of bisphosphonates reduces the risk of vertebral fracture (odds ratio 0.69), nonvertebral fracture (odds ratio 0.65), and hypercalcemia (odds ratio 0.54). Current evidence supports the empirical initiation of bisphosphonates in patients with bone metastases. Radiopharmaceuticals such as strontium-99 are predominantly used to manage severe, refractory pain associated with widely disseminated bone metastases. Drawbacks to radiopharmaceuticals include prolonged marrow suppression and potentially severe pain flares following administration.

Radiation delivered to bone metastasis offers an effective means of rapidly achieving local control of pain and tumor growth. Palliative radiation was formerly delivered in 10 fractions of 300 cGy. However, single fractions of 8 Gy also effectively alleviate pain. At present, protocols in use range between these extremes with the choice of dose and schedule being heavily influenced by individual patient factors and institutional culture. Radiation may be delayed following surgical stabilization. However, it is an important adjunctive treatment because it suppresses tumor growth in areas where surgical management may have distributed microscopic emboli.

Painful osteolytic lesions are predominantly responsible for pathologic fractures. The incidence of pathologic fracture among all cancer types is 8%. Breast carcinoma is responsible for approximately 53% of these. Other solid tumors associated with pathologic fractures are kidney, lung, thyroid cancer, and lymphoma. Sixty percent of all long bone fractures involve the femur, with 80% of these located in the proximal portion.

Management bone metastases that may fracture remains a source of clinical uncertainty. Precise quantification of fracture risk has been a persistent challenge in orthopedic oncology. Table 29-3 outlines Mirel’s proposed rating system for calculating fracture risk, whereby specific attributes are ascribed points. Neither this, nor any other approach based on retrospective review, has been adequately validated in clinical practice.

Pathologic fractures are generally managed through well-established surgical algorithms. Four main goals direct surgical management of pathologic fractures: pain relief, preservation or restoration of function, skeletal stabilization, and local tumor control. The general indications for surgery are life expectancy of more than 1 month with a fracture of a weight-bearing bone, and more than 3 months for fracture of a non–weight-bearing bone. Internal fixation or prosthetic replacements with polymethylmethacrylate are the most effective ways of relieving pain and restoring function in patients with pathologic fractures. Healing rates may be low following pathologic fractures.

Fractures of the pelvis are generally treated conservatively, unless pain persists after radiation or they involve the acetabulum. In the latter case, patients are generally surgically reconstructed with screws or pins, and with an acetabular component. Vertebral fractures that are not associated with neurologic compromise are generally treated conservatively with radiation and bracing. Operative decompression and stabilization may be indicated for persistent pain refractory to aggressive analgesic therapy. Vertebroplasty continues to be performed for patients who are not at risk of tumor displacement into the spinal canal. However, two large randomized controlled trials failed to demonstrate benefit in compression fractures related to osteoporosis, and these results have raised skepticism regarding the benefit of vertebroplasty in cancer.

Brain Tumors: Primary and Metastases

Brain metastases occur in 15% to 40% of patients with cancer, accounting for 200,000 new cases per year in the United States. They are the most common intracranial tumors. The incidence has increased in recent years, presumably as a result of prolonged patient survival and better early detection of small tumors through superior imaging modalities. Lung cancer is the most common primary source of brain metastases. Up to 64% of patients with stage IV lung cancer develop brain metastases. Breast cancer is the second most common source, followed by melanoma, with 2% to 25% and 4% to 20% of patients developing brain metastases, respectively. Brain metastases from colorectal cancers, genitourinary cancers, and sarcomas occur with considerably less frequency (1%). The distribution of metastases reflects cerebral blood flow, with 90% situated in the supratentorial region and 10% in the posterior fossa. Brain metastases are multiple in approximately 50% to 75% of cases.

Epidural Spinal Cord Compression

Malignant spinal cord compression (SCC) occurs in up to 5% of patients. In contrast to brain metastases, which involve the brain parenchyma, most symptomatic tumors compress the spinal cord or cauda equina from the epidural space. Epidural lesions generally arise from vertebral metastases and rarely breach the dura. Invasion of the dural space accounts for only 5% of neoplastic SCC and is caused by either growth of tumor along the spinal roots or hematogenous spread to the cord. The cancers that most commonly cause SCC are those that produce vertebral metastases (e.g., breast, lung, myeloma, and prostate).

Cranial Nerves

Cranial nerve palsies are caused by tumors that originate near the base of the skull or metastasize there. Cancer can directly invade cranial nerves or exogenously compress them. Often, tumors invade the neural foramina. Bone metastases from lung, breast, and prostate cancers involving the base of the skull are also common sources of cranial nerve compromise. The incidence with which different cranial nerves are affected by cancer remains poorly quantified. One series of patients with breast cancer reported a 13% incidence of cranial nerve dysfunction. The trigeminal and facial nerves were most frequently involved.

Clinical presentations vary depending on the cranial nerve being compressed. Evaluation should include MRI, which is the diagnostic test of choice. If patients have a bone-avid tumor (e.g., lung, breast, or prostate), a CT scan should be considered, because bone destruction is more easily observed on CT scan. Positron emission tomography (PET) scanning particularly in conjunction with CT scanning can help to discretely localize the tumor if extensive postradiation change or surgical alteration of the bony architecture has occurred. Acute management should include oral steroids, unless contraindicated, to preserve neurologic function until definitive treatment is delivered. Treatment generally involves chemotherapy and radiation.

Spinal Roots

Malignant radiculopathies arise through direct hematogenous spread to the nerve roots or dorsal root ganglia, or, more commonly, by invasion from the paravertebral space. When the latter occurs, the tumor can grow longitudinally in the paravertebral space and concurrently invade multiple foramina to produce a polyradiculopathy. Most cancer-related radiculopathies initially produce dysesthetic, aching, or burning pain in the affected dermatome, which can be associated with lancinations. Sympathetic hyperactivity or hypoactivity can be present. Involvement of the lower cervical or upper thoracic roots can produce a Horner syndrome. In patients with a history of cancer, a new Horner syndrome should be attributed to malignancy until proven otherwise. Patients may complain of muscle cramps in affected myotomes.

Nerve Plexuses

The brachial and lumbosacral plexuses are commonly compressed or invaded by tumor. The frequency of malignant brachial plexopathy is 0.43%, and lumbosacral plexopathy 0.71%, based on retrospective case series. The most common sources of brachial plexopathy are tumors at the lung apex and regional spread of breast cancer. Because cancer generally grows superiorly to invade the lower brachial plexus, the inferior trunk and medial cord are most commonly involved. Occasionally, head and neck neoplasms grow inferiorly to invade the upper trunk.

Pain in the shoulder region and proximal arm occurs in 89% of patients with malignant brachial plexopathy and is the most common presenting symptom. The presence of pain helps to distinguish malignant from radiation-induced plexopathy. Only 18% of patients with radiation-induced plexopathy develop pain. Radiation plexopathies also differ in their propensity to cause progressive weakness in the C5 to C6 myotomes as opposed to the lower cervical levels. Horner’s syndrome occurs in 23% of patients with cancer who have malignant brachial plexopathies. The presence of Horner’s syndrome suggests potential neuroforaminal encroachment and SCC. Numbness and paresthesias associated with malignant plexopathies typically are perceived in the C8 dermatome, especially digits 4 and 5. Loss of hand dexterity and power can be the initial motor complaint. Weakness subsequently extends proximally to involve the finger flexors, wrist extensors and flexors, and elbow extensors.

Malignancies responsible for lumbosacral plexopathies include colorectal carcinomas; retroperitoneal sarcomas; or metastatic tumors from breast, lymphoma, uterus, cervix, bladder, melanoma, or prostate. If primary intrapelvic neoplasms are not responsible, then the lumbosacral plexus is generally invaded from lymphatic and osseous metastases. Sacral plexopathies are more common than those in the lumbar region. Lumbar and sacral plexopathies can also occur concurrently. Lumbosacral plexopathies are bilateral in 25% of patients, particularly when the sacral plexus is more extensively involved. Incontinence and impotence strongly suggest bilateral involvement. Back, buttock, or leg pain is present in 98% of patients with malignant lumbosacral plexopathies. Among the 60% of patients who eventually develop neurologic deficits, 86% have leg weakness and 73% have sensory loss. Positive straight leg raise is present in over 50% of patients. As many as 33% of patients complain of a “hot dry foot” resulting from involvement of sympathetic components of the plexus.

Peripheral Nerves

Peripheral nerves are affected most often by cancer when extension of a bone metastasis produces a mononeuropathy. Rare polyneuropathy or mononeuritis multiplex resulting from myeloma, lymphoma, or leukemia has been reported. More commonly, nerves are compressed where they pass directly over an involved bone or through a bony canal. Common sites of nerve compression include the radial nerve at the humerus, obturator nerve at the obturator canal, ulnar nerve at the elbow and axilla, sciatic nerve in the pelvis, intercostal nerves, and peroneal nerve at the fibular head. Pain generally precedes motor and sensory loss.

Paraneoplastic Syndromes

Paraneoplastic syndromes are pertinent to rehabilitation because they produce refractory neurologic deficits and severe disability. The incidence of paraneoplastic neurologic disorders (PNDs) is low, occurring in less than 1% of all patients with cancer. PNDs may affect any level of the nervous system. Classic PNDs are listed in Table 29-4 . These syndromes are produced when antibodies are made against tumors that express nervous system proteins. Most PNDs are triggered during the early stages of cancer, when primary tumors and metastases may be undetectable by conventional imaging techniques. The emergence of a PND in a patient with known cancer should trigger workup for recurrent or progressive disease. PNDs are characterized by symptoms that develop and progress rapidly in days to weeks, and then stabilize. Spontaneous improvement is rare. Diagnostic workup may include serum and cerebrospinal fluid tests, brain MRI, and PET. Screening patients’ serum or cerebrospinal fluid for antineuronal antibodies known to be associated with particular cancers can direct the search for an occult malignancy. Timely diagnosis and treatment of the tumor offer the greatest chance of success in managing PNDs. PNDs do not generally respond solely to immunotherapies (e.g., intravenous immunoglobulin, corticosteroids, and immunosuppressants) or to plasmapheresis. However, these may be useful adjuvant treatments.

Rehabilitation of PNDs is determined by the type, distribution, and severity of the associated neurologic deficits. Potential improvement with planned antineoplastic therapy should be taken into consideration. Supportive and preventive measures to protect the integrity of the skin, affected joints, and genitourinary symptoms are crucial while awaiting stabilization of neurologic deficits. Communication, respiratory, and nutritional issues should be addressed in patients with bulbar involvement.

Skin Metastases

Dermal metastases occur in 5.3% of patients and are most common in breast cancer. Skin metastases can be a source of pain and an entry point for infectious pathogens. Because the associated wounds seldom heal, chronic wound care is necessary and becomes an integral part of patients’ rehabilitation needs. Figure 29-1 shows a patient with breast cancer who has dermal metastases involving the breast and proximal arm. Dermal metastases may engender or aggravate lymphedema. Use of compression is limited only by patient tolerance. Malignant wounds should be managed with nonadherent, bacteriostatic, hyperabsorbent dressings (e.g., SilvaSorb or Aquacel Ag). Associated pain must be managed aggressively to minimize adverse functional consequences. Proactive range of motion (ROM) will prevent the formation of contractures in joints adjacent to malignant wounds, facilitating hygiene and autonomous self-care.

Skin metastases producing nonhealing wounds in a patient with breast cancer.

Cardiopulmonary Metastases

Lung, pleural, and pericardial metastases involving the heart and lungs can produce dramatic and abrupt reductions in patients’ stamina and functional status. Virtually all cancers have the potential to spread to the lungs and pleura. At autopsy, 25% to 30% of all patients with cancer have lung metastases. Pleural metastases occur in 12% of breast and 7% to 15% of lung cancers. Metastases to the heart and pericardium are less common, although their functional impact can be similarly devastating. A series of 4769 autopsies revealed the presence of cardiac metastases in 8.4% of patients with cancer. Melanoma, mesothelioma, lung tumors, and renal neoplasms had the highest prevalence of cardiac spread. The clinical diagnosis of heart or lung metastases can be generally made by CT scans. PET scans and plain x-rays may also be helpful, depending on the clinical context.

Treatment of lung, pleural, pericardial, or cardiac metastases varies considerably. The type and efficacy of anticancer treatment will depend on the primary tumor, number and location of metastases, previous antineoplastic therapies, overall medical condition of the patient, and degree of associated symptomatic distress. Surgical metastasectomy has the potential to definitively eliminate disease in certain patients. Discrete metastases that are not resectable may be amenable to radiation therapy.

Malignant pleural effusions should be evacuated when patients become symptomatic. However, the associated dyspnea often arises from other causes also, and reducing the effusion may fail to alleviate patients’ shortness of breath if the lung is trapped because of parenchymal or pleural disease. Reaccumulation of malignant effusions can be managed through intermittent thoracentesis or pleurodesis, or placement of an indwelling pleural catheter. Chemical pleurodesis has an overall complete response rate of 64% when all sclerotic agents are considered. Talc appears the most effective, with a complete response rate of 91%.

The functional relevance of heart and lung metastases stems from their deleterious effect on patients’ aerobic capacity. Small reductions in cardiopulmonary reserve can devastate patients who are deconditioned or have other impairments. For this reason, all potentially treatable causes should be definitively addressed. Supplemental oxygen should be initiated as soon as dyspnea becomes function-limiting. In this way, patients can engage in rehabilitation and potentially remain independent and ambulatory. If tolerated, gradual, progressive aerobic conditioning will optimize peripheral conditioning, reducing the percentage of V o _2max required for activities. Referral for outpatient aerobic training should be considered when patients with cancer who have cardiopulmonary disease are hospitalized for other problems (e.g., neutropenic fever). These patients are prone to rapid functional decline that usually proves permanent in the absence of structured therapy.

Combined Modality Therapy

The push toward organ preservation in primary cancer care has led to widespread use of combined modality therapy. Clinical trials have consistently shown that concurrent or sequential administration of radiation and chemotherapy reduces the extent of tissue resection required to achieve local cancer control without compromising 5-year survival rates. The trend toward use of combined modality therapy is relevant to rehabilitation because most patients with cancer receive some combination of chemotherapy, radiation therapy, or surgery contingent on the type and stage of cancer. This renders patients vulnerable to cumulative normal tissue toxicities associated with each modality.

Surgery-Related Impairments

Primary impairments resulting from surgery depend on the extent, location, and type of tumor. Normal tissue is inevitably affected by surgical efforts to achieve local control of cancer. The principal reasons for resecting normal tissue, with the associated risk of adverse long-term consequences, include accurate staging (e.g., sampling of lymph nodes, and visceral and parietal peritoneum), definitive eradication of tumor, assurance of local disease control (e.g., removal of lymph nodes that might harbor cancer cells), and harvest for reconstructive purposes.

Cancer surgery has the greatest physiatric relevance when certain tissue types are affected. These tissues include bone, nerve, muscle, lung parenchyma, and lymphatics. Normal postoperative healing is often compromised by the previous or coadministration of additional anticancer treatment(s) (e.g., radiation and chemotherapy).

The list of established surgical approaches to eradicate tumors is vast, and readers are referred to Surgical Oncology: Contemporary Principles and Practice (edited by Bland) for more precise and extensive procedure-specific discussions. Operations that commonly warrant the attention of a physical medicine specialist include neck dissection for oropharyngeal carcinomas (spinal accessory nerve palsy), limb salvage or amputation for osteosarcoma (impairments vary by site), resection of truncal or limb myosarcoma (weakness, gait dysfunction, biomechanical imbalance), axillary lymph node dissection (shoulder contracture, lymphedema), and pneumonectomy or lobectomy for lung neoplasms (aerobic insufficiency). Procedures such as nephrectomy, colectomy, mastectomy, and oophorectomy may involve the resection of muscles, nerves, or vessels to achieve clean margins resulting in acute functional losses. Review of patients’ surgical reports is essential to accurately identify all potential neuromuscular and lymphatic compromise.

Neurosurgical resection of central and peripheral nervous system cancers warrants physiatric evaluation, irrespective of the presence of gross deficits, given the potentially devastating effects of subtle impairments and the high likelihood of future recurrence and progression.

Secondary Impairments

Secondary surgery-associated impairments often emerge well after, presenting as familiar musculoskeletal problems (e.g., tendinopathies and arthropathies). Patients’ compensatory attempts to negotiate impairments during mobility and ADL performance may produce maladaptive movement patterns, which may, in turn, engender secondary pain sources and impairments. A common example is myofascial dysfunction of the scapular retractors, middle trapezius, and rhomboid muscles as a result of pectoralis major and minor tightness following mastectomy or chest wall radiation and breast implant insertion. Secondary impairments are fortunately readily reversible through timely physiatric evaluation and treatment.

Donor Site Morbidity

Donor site morbidity associated with surgical tissue harvest for reconstructive purposes produces significant impairments less often than might be anticipated. Muscle, skin, bone, and fat are used to achieve adequate coverage of surgical defects and to optimize cosmesis. Radial forearm and fibular flaps are commonly harvested to eliminate defects produced by mandibular resection. Both are typically well tolerated and seldom produce functional deficits. Impairments associated with the harvest of myocutaneous flaps vary by extent and site, and are no different in cancer than in other rehabilitation cohorts. Partial transposition of the pectoralis major muscle from its insertion on the humerus has been used to repair soft tissue defects involving the anterolateral neck. This procedure can destabilize the shoulder in the absence of therapeutic intervention.

By virtue of the high incidence of breast cancer, significant donor site morbidity is most prevalent with autogenous tissue transposition for breast reconstruction. Among women undergoing breast reconstruction in 2008, implants were the most common procedure (60.5%), followed by pedicled flaps (34%) and microsurgical flaps (5.5%). Transverse rectus abdominis muscle (TRAM), gluteus maximus, deep inferior epigastric perforator (DIEP), and latissimus myocutaneous flaps are used, with the former being more common. With a relatively low complication rate (25.3%) and potentially excellent cosmesis ( Figure 29-2 ), the TRAM flap procedure is a common choice, given the potential to create a natural-looking breast with normal ptosis and an inframammary fold. Comparison of functional morbidity following the TRAM and DIEP procedures suggests that they are not markedly different. More patients are electing to undergo immediate breast reconstruction to reduce the risk associated with repeat operations and the psychological distress engendered by mastectomy.

Excellent cosmesis achieved with bilateral transverse rectus abdominis flap breast reconstructions.

The TRAM procedure involves the transposition of muscle and adipose tissue to match preoperative breast appearance ( Figure 29-3 ). Other advantages of the TRAM procedure include relatively hidden scars and a satisfactory donor site resulting in a flat abdomen. The TRAM flap can be divided into the pedicled or free flap procedures.

The transverse rectus abdominis flap procedure uses the superior epigastric artery to supply blood to the subumbilical fat, which is used to reconstruct the mastectomized breast. The fat and inferior ends of the rectus muscle are tunneled under the abdominal wall into the defect caused by mastectomy.

These procedures differ in that the pedicled, or conventional, procedure uses the epigastric vessels supplying the rectus muscle to perfuse the subumbilical fat. Subumbilical adipose tissue is tunneled under the abdominal skin to repair the defect created by mastectomy. The inferior end of the contralateral rectus abdominis muscle is tunneled with the fat (see Figure 29-3 ). In contrast, the free flap procedure involves the creation of anastomoses with vessels in the chest such as the thoracodorsal or internal mammary arteries. Although the free flap procedure requires increased operative time, it is associated with decreased incidence of partial flap loss resulting from fat necrosis.

Despite declining perioperative complication rates, the adverse musculoskeletal sequelae of TRAM flap breast reconstruction can be significant. Donor site complications include abdominal wall bulge (2.9% to 3.8%), abdominal hernia (2.6% to 2.9%), and dehiscence (3.8%). Patients experience abdominal weakness and reduced exertional tolerance, particularly those undergoing bilateral procedures. Because the TRAM procedure produces a defect in the abdominal wall, patients have difficulty stabilizing the trunk while transferring from supine and seated positions. Partial denervation of the abdominal wall also leads to deficits in proprioception and truncal balance. Weakness of the abdominal wall can lead to exaggerated lumbar lordosis and an increased incidence of back pain. An algorithm for treatment of patients post–TRAM flap is presented later in this chapter under “Rehabilitation of Specific Cancer Populations.”