EpistemisMetastatic pleuritic localized rib pain
Specialty: Respiratory.
Why it occurs
- Osteolytic rib metastasis secondary to lung adenocarcinoma (tumor growth destroys the costal cortex and directly invades the periosteum and adjacent parietal pleura, generating stabbing and intolerant pain intensely localized over the affected rib that is exacerbated by deep respiratory movements and cough, simulating a rub or classic pleuritic pain)
- Peripheral bronchial carcinoma with direct invasion of the anterior or posterior costal wall (Pancoast syndrome or similar)
- Multiple myeloma with localized costal lytic lesion and reactive pleural infiltration.
Initial workup
Oblique costal chest x-ray; High-resolution chest computed tomography (CT) (HRCT); bone scan with technetium-99m; Magnetic resonance imaging (MRI) of the chest wall; Core needle biopsy of the rib lesion guided by CT or ultrasound.
red flags
Pain refractory to major opiates, palpable swelling with bone crepitation over the rib (suggestive of an imminent pathological fracture), rapidly progressive dyspnea, or motor weakness in the lower extremities (if associated with simultaneous metastatic spinal cord compression).
Standard management
- Fentanyl — transdermal patch, initiated at doses of 12-25 micrograms/hour every 72 hours for severe cancer pain
- Morphine — oral solution, 5-10 mg every 4 hours for the control of breakthrough pain when coughing or moving
- Ibuprofen — 400-600 mg orally every 8 hours with food to enhance bone analgesia by inhibition of peristomal prostaglandins
- Zoledronic acid (4 mg intravenously every 4 weeks to reduce skeletal complications and bone pain from metastasis).
Educational guidance for study. It is NOT a prescription recommendation. The actual choice depends on the cause, the patient, and current guidelines.
- Area
- Respiratory
- Listed causes
- 3
- Treatment options
- 4