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Your Good Health: Relentless pain occuring after a biopsy calls for a specialist

Since having a lung biopsy, my friend has been in constant excruciating pain. What should his next move be?
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Dr. Keith Roach

Dear Dr. Roach: I have a 72-year-old male friend in excellent health. Approximately six months ago, he had difficulty breathing and subsequently had fluid drained from his left lung. He worked with asbestos in his earlier years, so a biopsy was performed, with benign results.

The surgeon who performed the surgery told him that his initial attempt was too low (he had aimed for the bottom section of the lung), so he made a second successful attempt.

Since the date of the biopsy (in early December 2022), my friend has been in constant excruciating pain in the area where the first biopsy was performed. He was prescribed nonnarcotic pain medication (ibuprofen — his choice), but the pain persisted. Neither the surgeon nor his primary care physician can tell him why he is in such pain three months after the procedure. (The surgeon suspects it may still be cancer and wants to do a second biopsy.) He is unable to sleep due to the discomfort.

He went to the emergency room, where a CT scan was performed to check for an abscess or a hematoma, neither of which was present. This past week he finally relented (he has concerns about addiction) and got a prescription for narcotic pain relief, which is helping him.

Do you have any insight as to what might be causing his unrelenting pain? Could the biopsy have caused nerve damage? What should his next move be?

J.R.

There is a well-described syndrome of pain after surgery, involving the pleura — the lining to the chest cavity and lung. Called post-thoracotomy pain syndrome, this can happen after a biopsy or after open surgery to the lung. By definition, it must last more than two months, and the quality is often described as a burning feeling. It’s not clear exactly what causes it, but it does seem to be more common in people with cancer, which may be one reason the surgeon remains concerned.

Asbestos exposure is a major risk for two different types of lung cancer. Nerve damage does seem likely, but exactly how it happens is controversial. It can happen after many different procedures.

In my opinion, his next move is a pain-management specialist. Pain due to nerve damage has other options besides ibuprofen and opiates, and the earlier he gets started, the better. In addition to medication treatment, several studies have shown that nerve blocks can be an effective treatment. Studies show that the pain gradually diminishes over time.

Dear Dr. Roach: I am not sure if the following is a commonly known fact, but according to my urologist, it is best to abstain from sexual relations three days before taking a PSA test, or the test result may be elevated.

K.O.

Sexual activity can increase the PSA level, but not by very much — by about 0.4 to 0.5 ng/mL. If a man is at a range where the PSA level is critical for the decision about a biopsy, it may be reasonable to avoid sexual activity for two or three days. Otherwise, I do not tell my patients they need to do so.

The use of medications to shrink the prostate, specifically finasteride (Proscar) and dutasteride (Avodart), decreases the PSA level by about half. This needs to be taken into consideration when a man starts these medicines. Prostate inflammation and infection can dramatically increase the PSA level, so men with symptoms should be treated before performing a PSA screening. The possibility of prostate inflammation is considered by a urologist before a biopsy. Inflammation is a common cause for a false-positive PSA, but sexual activity is not.

Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu