Effective treatment of the brachial plexus syndrome in breast cancer patients by early detection and control of loco-regional metastases with radiation or systemic therapy

Towards a practical use of text mining approaches in electrodiagnostic data

Healthcare professionals produce abounding textual data in their daily clinical practice. Text mining can yield valuable insights from unstructured data. Extracting insights from multiple information sources is a major challenge in computational medicine. In this study, our objective was to illustrate how combining text mining techniques with statistical methodologies can yield new insights and contribute to the development of neurological and neuromuscular-related health information. We demonstrate how to utilize and derive knowledge from medical text, identify patient groups with similar diagnostic attributes, and examine differences between groups using demographical data and past medical history (PMH). We conducted a retrospective study for all patients who underwent electrodiagnostic (EDX) evaluation in Israel's Sheba Medical Center between May 2016 and February 2022. The data extracted for each patient included demographic data, test results, and unstructured summary reports. We conducted several analyses, including topic modeling that targeted clinical impressions and topic analysis to reveal age- and sex-related differences. The use of suspected clinical condition text enriched the data and generated additional attributes used to find associations between patients' PMH and the emerging diagnosis topics. We identified 6096 abnormal EMG results, of which 58% (n = 3512) were males. Based on the latent Dirichlet allocation algorithm we identified 25 topics that represent different diagnoses. Sex-related differences emerged in 7 topics, 3 male-associated and 4 female-associated. Brachial plexopathy, myasthenia gravis, and NMJ Disorders showed statistically significant age and sex differences. We extracted keywords related to past medical history (n = 37) and tested them for association with the different topics. Several topics revealed a close association with past medical history, for example, length-dependent symmetric axonal polyneuropathy with diabetes mellitus (DM), length-dependent sensory polyneuropathy with chemotherapy treatments and DM, brachial plexopathy with motor vehicle accidents, myasthenia gravis and NMJ disorders with botulin treatments, and amyotrophic lateral sclerosis with swallowing difficulty. Summarizing visualizations were created to easily grasp the results and facilitate focusing on the main insights. In this study, we demonstrate the efficacy of utilizing advanced computational methods in a corpus of textual data to accelerate clinical research. Additionally, using these methods allows for generating clinical insights, which may aid in the development of a decision-making process in real-life clinical practice.

Neoplastic nerve lesions

Though metastasis and malignant infiltration of the peripheral nervous system is relatively rare, physicians should have a familiarity with their presentations to allow for prompt diagnosis and initiation of treatment. This article will review the clinical presentations, diagnostic evaluation, and treatment of neoplastic involvement of the cranial nerves, nerve roots, peripheral nerves, and muscle. Due to the proximity of the neural structure traversing the skull base, metastasis to this region results in distinctive syndromes, most often associated with breast, lung, and prostate cancer. Metastatic involvement of the nerve roots is uncommon, apart from leptomeningeal carcinomatosis and bony metastasis with resultant nerve root damage, and is characterized by significant pain, weakness, and numbness of an extremity. Neoplasms may metastasize or infiltrate the brachial and lumbosacral plexuses resulting in progressive and painful sensory and motor deficits. Differentiating neoplastic involvement from radiation-induced injury is of paramount importance as it dictates treatment and prognosis. Neurolymphomatosis, due to malignant lymphocytic infiltration of the cranial nerves, nerve roots, plexuses, and peripheral nerves, deserves special attention given its myriad presentations, often mimicking acquired demyelinating neuropathies.

Oral Methadone for Patients With Neuropathic Pain Due to Neoplastic Brachial Plexopathy

INTRODUCTION

The brachial plexus nerves originate from the cervical (C5-C8) and first thoracic (T1) spinal nerves, and innervate muscles and skin of the chest, shoulder, arm and hand. Brachial plexus injuries can occur as a result of shoulder trauma and inflammation. Malignant tumors can also cause neoplastic brachial plexopathy (NBP), and refractory neuropathic pain is the most common symptom of NBP. Methadone is a synthetic opioid with high efficacy as an opioid-receptor agonist, and its inhibitory effects on N-methyl-D-aspartate (NMDA) may play a role in pain relief. However, there is a need to examine if oral methadone exhibits safety and efficacy against neuropathic pain due to NBP.

CASE PRESENTATIONS

NBP was diagnosed in 3 cases without brain or cervical spine metastasis. The clinical features of these patients were analyzed retrospectively. None of the cases had an indication for surgery because of advanced cancer and all had received radiation therapy that had an insufficient effect, prior to methadone treatment. All 3 patients had nociceptive and neuropathic pain. Methadone for refractory pain was initiated using the stop-and-go method. NRS pain scores decreased in all cases and there were no severe side effects.

DISCUSSION

For the purpose of pain relief, patients with NBP may receive surgery, radiation therapy and nerve block, but these are not always effective. Methadone was recently shown to be superior to fentanyl in treating neuropathic pain in patients with head-and-neck cancer in a RCT, and our findings suggest that methadone may also be effective for patients with NBP.

CONCLUSION

More studies are necessary, but results in 3 cases suggest that oral methadone may be a safe analgesic agent for patients with neuropathic pain due to NBP.

Brachial and lumbosacral plexopathies: A review

Diseases of the brachial and lumbosacral plexus are uncommon and complex. The diagnosis of plexopathies is often challenging for the clinician, both in terms of localizing a patient's symptoms to the plexus as well as determining the etiology. The non-specific clinical features and similar presentations to other root, nerve, and non-neurologic disorders emphasize the importance of a high clinical index of suspicion for a plexopathy and comprehensive clinical evaluation. Various diagnostic tests, including electrodiagnostic (EDX) studies, neuroimaging (including ultrasound, MRI, or PET), serologic studies, and genetic testing, may be used to confirm a plexopathy and assist in identifying the underlying etiology. EDX testing plays an important role in confirming a plexopathy defining the localization, pathophysiology, chronicity, severity, and prognosis. Given the complexity of the plexus anatomy, multiple common and uncommon NCS and an extensive needle examination is often required, and a comprehensive, individualized approach to each patient is necessary. Treatment of plexopathies often focuses on symptomatic management although, depending on the etiology, specific targeted treatments may improve outcome. This article reviews the clinical features, EDX approaches, and evaluation and treatment of brachial and lumbosacral plexopathies.

Effect of external breast prosthesis mass on bra strap loading and discomfort in women with a unilateral mastectomy

BACKGROUND

A common complaint of women who wear external breast prostheses following mastectomy is that they are too heavy. This study aimed to investigate the effect of external breast prosthesis mass on bra strap loading, discomfort and perceived pressure in women with a unilateral mastectomy.

METHODS

Pressures exerted at the bra strap-shoulder interface and ratings of discomfort and perceived pressure (visual analogue scales; 0-12 cm) were recorded for 17 women (mean 68 (SD 5.7) years) who had a unilateral mastectomy. Data were collected during standing and walking while the women wore a Lightweight prosthesis and Standard-weight prosthesis. Pressure, discomfort and perceived pressure between the two prosthesis conditions were compared using Wilcoxon Signed Ranks and the sum of the pressure values during walking and standing were correlated with discomfort and perceived pressure scores using Spearman's Rho tests.

FINDINGS

Mean peak bra strap pressures were significantly less when the participants wore the Lightweight prosthesis compared to the Control prosthesis during walking (0.28 (SD 0.14) N/cm² versus 0.35 (SD 0.20) N/cm²; P < 0.05) but not during standing. No significant main effect of prosthesis mass on the participants' ratings of discomfort or perceived pressure were found, which were highly variable.

INTERPRETATION

Reducing external breast prosthesis mass decreased mean peak bra strap pressures during walking but this was not accompanied with reductions in bra strap-shoulder discomfort or perceived pressure. Treatment strategies to decrease bra strap-shoulder interface loading due to external breast prostheses mass could assist women who complain of prosthesis heaviness during physical activity.

Plexus and peripheral nerve metastasis

Cancer in the form of solid tumors, leukemia, and lymphoma can infiltrate and metastasize to the peripheral nervous system, including the cranial nerves, nerve roots, cervical, brachial and lumbosacral plexuses, and, rarely, the peripheral nerves. This review discusses the presentation, diagnostic evaluation, and treatment options for metastatic lesions to these components of the peripheral nervous system and is organized based on the anatomic distribution. As skull base metastases (also discussed in Chapter 14) result in cranial neuropathies, these will be covered in detail, as well as cancers that directly infiltrate the cranial nerves. Particular emphasis is placed on the clinical, imaging, and electrodiagnostic features that differentiate neoplastic plexopathies from radiation-induced plexopathies. Neurolymphomatosis, in which malignant lymphocytes invade the cranial nerves, nerve roots, brachial and lumbosacral plexuses, and peripheral nerves, is a rare manifestation of lymphoma and leukemia. Diagnoses of neurolymphomatosis are often missed or delayed given its varied presentations, resulting in poorer outcomes. Thus this disease will also be discussed in depth.

CE: Late and Long-Term Sequelae of Breast Cancer Treatment

: More than 12% of women will be diagnosed with breast cancer at some point in their lives, and 78% of them can be expected to survive for at least 15 years. More than 2.8 million breast cancer survivors currently reside in the United States. After breast cancer treatment, as many as 90% of survivors report physical problems that can reduce functional ability, produce or exacerbate emotional problems, negatively affect body image, and diminish quality of life. Many survivors will seek care for late and long-term effects of treatment, which will not necessarily be recognized as such by health care providers and appropriately treated. In this article, the authors discuss the underlying causes of late and long-term sequelae of breast cancer treatment and describe effective assessment and management strategies. They focus specifically on the most common and potentially debilitating upper body effects of breast cancer surgery and external radiation therapy: lymphedema, axillary web syndrome, postmastectomy pain syndrome, rotator cuff syndrome, adhesive capsulitis, arthralgias, cervical radiculopathy, and brachial plexopathy.

Lymphatic endothelial cells support tumor growth in breast cancer

Tumor lymphatic vessels (LV) serve as a conduit of tumor cell dissemination, due to their leaky nature and secretion of tumor-recruiting factors. Though lymphatic endothelial cells (LEC) lining the LV express distinct factors (also called lymphangiocrine factors), these factors and their roles in the tumor microenvironment are not well understood. Here we employ LEC, microvascular endothelial cells (MEC), and human umbilical vein endothelial cells (HUVEC) cultured in triple-negative MDA-MB-231 tumor-conditioned media (TCM) to determine the factors that may be secreted by various EC in the MDA-MB-231 breast tumor. These factors will serve as endothelium derived signaling molecules in the tumor microenvironment. We co-injected these EC with MDA-MB-231 breast cancer cells into animals and showed that LEC support tumor growth, HUVEC have no significant effect on tumor growth, whereas MEC suppress it. Focusing on LEC-mediated tumor growth, we discovered that TCM-treated LEC (‘tumor-educated LEC') secrete high amounts of EGF and PDGF-BB, compared to normal LEC. LEC-secreted EGF promotes tumor cell proliferation. LEC-secreted PDGF-BB induces pericyte infiltration and angiogenesis. These lymphangiocrine factors may support tumor growth in the tumor microenvironment. This study shows that LV serve a novel role in the tumor microenvironment apart from their classical role as conduits of metastasis.

Clinical, Electrophysiological Findings in Adult Patients with Non-traumatic Plexopathies

Objective

To ascertain the etiology of non-traumatic plexopathy and clarify the clinical, electrophysiological characteristics according to its etiology.

Method

We performed a retrospective analysis of 63 non-traumatic plexopathy patients that had been diagnosed by nerve conduction studies (NCS) and needle electromyography (EMG). Clinical, electrophysiological, imaging findings were obtained from medical records.

Results

We identified 36 cases with brachial plexopathy (BP) and 27 cases with lumbosacral plexopathy (LSP). The causes of plexopathy were neoplastic (36.1%), thoracic outlet syndrome (TOS) (25.0%), radiation induced (16.7%), neuralgic amyotrophy (8.3%), perioperative (5.6%), unknown (8.3%) in BP, while neoplastic (59.3%), radiation induced (22.2%), neuralgic amyotrophy (7.4%), psoas muscle abscess (3.7%), and unknown (7.4%) in LSP. In neoplastic plexopathy, pain presented as the first symptom in most patients (82.8%), with the lower trunk of the brachial plexus predominantly involved. In radiation induced plexopathy (RIP), pain was a common initial symptom, but the proportion was smaller (50%), and predominant involvements of bilateral lumbosacral plexus and whole trunk of brachial or lumbosacral plexus were characteristic. Myokymic discharges were noted in 41.7% patients with RIP. Abnormal NCS finding in the medial antebrachial cutaneous nerve was the most sensitive to diagnose TOS. Neuralgic amyotrophy of the brachial plexus showed upper trunk involvement in all cases.

Conclusion

By integrating anatomic, pathophysiologic knowledge with detailed clinical assessment and the results of ancillary studies, physicians can make an accurate diagnosis and prognosis.