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Research
 

Clinical Question: Is CRPS-I associated with malignancy?

Clinical Bottom line: Yes, CRPS-I has been reported to be associated with various cancers and may manifest as a paraneoplastic syndrome.

Search Profile

Databases

Pubmed

ISI Current contents

The Cochrane Library, Issue 2, 2002. Oxford: Update Software. Updated quarterly

Citations used for evidence:

Goldberg MI, Kennedy SF. Reflex sympathetic dystrophy--recognition and management in gynecologic oncology. Gynecol Oncol. 1979 Dec;8(3):288-95

Medsger TA, Dixon JA, Garwood VF. Palmar fasciitis and polyarthritis associated with ovarian carcinoma. Ann Intern Med. 1982 Apr;96(4):424-31

Michaels RM, Sorber JA.Reflex sympathetic dystrophy as a probable paraneoplastic syndrome: case report and literature review. Arthritis Rheum. 1984 Oct;27(10):1183-5

Taggart AJ, Iveson JM, Wright V. Shoulder-hand syndrome and symmetrical arthralgia in patients with tubo-ovarian carcinoma. Ann Rheum Dis. 1984 Jun;43(3):391-3.

Goldberg E, Dobransky R, Gill R. Reflex sympathetic dystrophy associated with malignancy. Arthritis Rheum.1985 Sep;28(9):1079-80.

Summers CL, Shahi M. Epithelioid sarcoma presenting as the reflex sympathetic dystrophy syndrome. Postgrad Med J. 1987 Mar;63(737):217-20.

Prowse M, Higgs CM, Forrester-Wood C, McHugh N. Reflex sympathetic dystrophy associated with squamous cell carcinoma of the lung. Ann Rheum Dis. 1989 Apr;48(4):339-41.

Regan M, Foley-Nolan D, McCarthy G, Coughlan RJ. Reflex sympathetic dystrophy associated with large cell lung carcinoma. Ann Rheum Dis. 1989 Dec;48(12):1031

Ameratunga R, Daly M, Caughey DE. Metastatic malignancy associated with reflex sympathetic dystrophy. J Rheumatol. 1989 Mar;16(3):406-7.

Malane SL, Sau P, Benson PM. Epithelioid hemangioendothelioma associated with reflex sympathetic dystrophy. J Am Acad Dermatol. 1992 Feb;26(2 Pt 2):325-8.

Derbekyan V, Novales-Diaz J, Lisbona R. Pancoast tumor as a cause of reflex sympathetic dystrophy. J Nucl Med. 1993 Nov;34(11):1992-4

Olson WL. Reflex sympathetic dystrophy associated with tumour infiltration of the stellate ganglion. J R Soc Med. 1993 Aug;86(8):482-3

Ku A, Lachmann E, Tunkel R, Nagler W. Upper limb reflex sympathetic dystrophy associated with occult malignancy. Arch Phys Med Rehabil. 1996 Jul;77(7):726-8.

The Studies:

» View the Demographics Study
» View the Results Study

Statistics

  • Age: Average – 55 yrs; Range 27-79
  • Gender: Male – 6; Female – 16
  • Cancer Type – Carcinoma – 18; Other – 4
  • Cancer Location: Reproductive tract – 9, Lung – 5, Extremity – 3, Other – 5
  • Metastasis detected - 9; Not detected – 13
  • RSD location: Unilateral – 12 Bilateral - 10

Upper limbs involved – Right – 14; Left – 10

Lower limbs involved – Right – 2; Left – 6

  • Treatment – Sympathetic block – 9;Physical Therapy – 6; Corticosteroids – 12
  • Symptomatic improvement:
    Some Pain relief – 13; No improvement –5; Disability worsened – 3; Not available – 1
  • Satisfied IASP criteria for diagnosis of CRPS-I – 9 out of 22 cases

The Evidence:

  • The average age of RSD patients in the series is 55 years with the youngest being 27 years and the oldest being 79 years old, suggesting that RSD with cancer can occur at any age.
  • Majority of the patients are observed to be females. This may be due to a generally higher prevalence of RSD in women.
  • Carcinomas from the reproductive tract and lung were the most common types of malignancy associated with concurrent RSD. Metastases were not reported as detected in majority of the cases.
  • The majority (80%) of patients with ovarian cancers are reported to have presented with bilateral upper extremity RSD.
  • The RSD location was unilateral in most cases with the majority confined to the upper limbs. Right and left sides were involved equally.
  • Majority of these cancer patients with RSD were treated with corticosteroids. Sympathetic blocks and physical therapy was administered less frequently than corticosteroids.
  • Twelve out of the total 22 cases of malignancy with concurrent RSD have not reported any noxious event or a cause of immobilization prior to the onset of RSD.
  • Pain and edema were the most commonly associated symptoms.

Comments:

  • Consistent with the review on this topic by Mekhail and Kapural1, in the majority of cases with malignancy and concurrent RSD/CRPS-I, the upper limbs were affected with RSD/CRPS-I.
  • While vulvar and cervical carcinomas were associated with RSD/CRPS-I in the lower limbs, ovarian malignancies were consistently associated with upper limbs and in most cases are bilateral.
  • The aim of this evidence report is to corroborate the coexistence of RSD/CRPS-I and malignancy, and to characterize the demographic and disease profile of patients reported to have had both conditions. There is no evidence of any specific treatment that is different from routine therapy that is effective in managing patients with concurrent RSD/CRPS-I and cancer.
  • About 40% of the reported patients met the current IASP criteria for CRPS-I. In more than 50% of patients, a noxious event or immobilization was not reported.

Reference

1. Mekhail N, Kapural L. Complex regional pain syndrome type I in cancer patients. Curr Rev Pain. 2000;4(3):227-33.

Appraised by: Prabhav Tella, July 2002

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