Breast Cancer Rehab & Lymphatics

What is the most common kind of breast cancer?

Invasive breast cancer (invasive ductal specifically)

What is the most aggressive type of breast cancer?

Inflammatory

What are the different avenues in which cancer can spread?

• The bloodstream

• Lymphatic system

• Direct extension into neighboring tissue or body cavities

What does “in situ” mean?

Malignant cells are present but have no metastasized or invaded beyond the original site where the tumor was discovered

How big is a T1 tumor?

Less than 2 cm (20 mm)

How big is a T2 tumor?

2-5 cm

How big is a T3 tumor?

>5 cm

How big is a T4 tumor?

Thing be so big that it has a direct extension to the chest wall and/or skin

What lymph nodes are involved if a tumor is rated N1?

Ipsilateral and mobile level I and II Axillary nodes

What lymph nodes are involved if a tumor is rated N2?

• Ipsilateral and matted level I and II Axillary nodes

• Ipsilateral internal mammary nodes only

What lymph nodes are involved if a tumor is rated N3?

• Ipsilateral level III Axillary nodes (infraclavicular node)

• Ipsilateral internal mammary nodes + level I, II nodes

• Ipsilateral supraclavicular nodes

What does the “M” stands for in the TNM staging system?

Presence of a distant metastasis

Describe stage 0 breast cancer

Ductal carcinoma in situ (DCIS) or lobular carcinoma in situ (LCIS), non-invasive cancers

Describe stage 1 breast cancer

Cancer only in the breast and the tumor be small (less than 2 cm)

Describe stage 2 breast cancer

Cancer in the breast that may be in a few nearby lymph nodes

Describe stage 3 breast cancer

Cancer be spreading into the breast and lymph nodes and may also involve the chest wall or skin

Describe stage 4 breast cancer

Cancer has spread to other parts of the body (aka it has done some metastasis)

When is fine needle aspiration used in breast tissue biopsy?

When ya gotta investigate a superficial lump or mass

What is removed with an incisional biopsy?

Section of a tumor

Describe a sentinel lymph node biopsy (SLNP)

A surgical procedure that removes one or more sentinel lymph nodes to check for cancer spread.

What level lymph nodes are removed in an axially lymph node dissection (ALND)?

Level I & II

What muscle is most commonly used to reconstruct a breast after surgery? Why?

Rectus abdominis muscle cuz it has a good amount of adipose tissue (lats is a back up)

What is the purpose of a surgical drain?

Prevent blood and lymphatic fluid buildup under the skin (aka don’t let a seroma happen)

What is the most frequent post-op complication after breast cancer surgery?

Seroma

What are the precautions when someone has a surgical drain in?

No shoulder flexion OR abduction over 90° until the drain is removed

How many weeks after starting radiation will someone start to develop red skin?

2-3 wks

You are treating a pt that is currently going through radiation for breast cancer. When do you have to stop doing manual therapy?

When their skin starts to turn red

What do you risk if you do MT with a pt who is undergoing radiation who has burned skin?

Desquamation

What are some ways to manage fibrosis that develops with radiation treatment?

• Deep tissue work

• Manual stretching

• Manual lymphatic drainage

• ROM

What are the side effects of chemotherapy?

• Fatigue

• Decreased WBC

• Hair loss

• Nausea and vomiting

• Neuropathies

• Pulmonary fibrosis

• Renal dysfunction

• Arrhythmia’s or ataxia

What is the most common drug given for hormonal therapy post breast cancer treatment?

Tamoxifen

What are the goals of PT when a pt is in the process of chemo?

• Minimize fatigue

• Maintain weight and muscle mass

• Get in some work! 20 min aerobic exercise 3-5x/wk

• Get em on an independent strength and flexibility program

• Promote a sense of active role in recovery

What abilities are affected when someone has cancer related cognitive impairment (CRCI)/chemo brain?

• Verbal ability (vocab, reading comprehension, verbal memory, verbal fluency)

• Visuospatial ability (visual memory, spatial orientation, constructional skills, navigational skills)

What are the most common breast cancer shoulder impairment syndromes?

• Myofascial restriction syndrome

• GLenohumeral capsular restriction syndrome

• Lymphedema syndrome

Describe neuromuscular coordination syndrome. What causes it?

The inability of the shoulder to produce coordinated movements due to disuse or nonuse. Person will have full PROM still

Describe pain syndrome. What causes it?

Peep who is in real bad pain and that’s what limits their movement. Pain is commonly the result of surgery or a neuropathy. Will be present at rest and decreased AROM and result in an empty end feel. However, PROM will still be full

Describe muscular force-production syndrome. What causes it?

Limitations in AROM to reduced strength as the result of disuse, nonuse, high pain reactivity, altered length tension relationships, or a resistance to movement. However, pt will have a normal end feel and normal PROM. Will still have good contractility

Describe peripheral neuropathic syndrome. What causes it?

When ya got a peripheral nerve not working with results in the muscles it innervates having a <2/5 MMT with poor contractility. Present with muscle atrophy and a joint deformity with AROM being more restricted than PROM. Caused by radiation, chemo, or surgery

Describe glenohumeral capsular restriction syndrome. What causes it?

When someone has limitations equally in AROM, PROM, and passive accessory movements due to disuse, no use, adhesive capsulitis, intra-articular edema, or capsular fibrosis. Pt will have a capsular end feel, a capsular pattern (ER>ABD>IR), and poor SH rhythm

Describe lymphedema syndrome. What causes it?

Reduction in shoulder mobility cuz the limb be weighing so much due to edema post-surgery or radiation

What is the most common syndrome with breast cancer?

Myofascial restriction syndrome/axillary web syndrome

Describe myofascial restriction/axillary web syndrome. What causes it?

Tense cords that run from the armpit, through the medial aspect of the arm, to the antecubital fossa, and that reach the thumb’s base. Commonly is the result of radiation, chemo, and/or surgery

What tissues most commonly make up axillary webbing?

• Lymphatic thromboses

• Venous thromboses

• Fibrosis lymphatic vessels

What are some risk factors for developing axillary webbing?

• Older

• Long surgery

• Lymph node involvement

• Complications during healing process

• Lower BMI

Any GH flex/abd restriction greater than ___° could be the result of cording

10°

What lymphedema measurements when compared between involved and uninvolved side would be considered significant?

• 10%+ difference in volume

• >200 mL difference in volume

• >2cm difference

When working with a pt with breast cancer, a VAS of __ or higher indicated a pain that induces physical impairment

3

What interventions are appropriate for treating neuromuscular coordination syndrome?

• Neuro re-ed with tactile and verbal cues, recitation, full and partial task practice

What interventions are appropriate for treating Pain syndrome?

• Modalities (No US)

• Meds

What interventions are appropriate for treating Muscular force production syndrome?

• Strengthening regimen

• Increased muscular force production

• Restoration of length-tension relationships

What interventions are appropriate for treating Peripheral neuropathic syndrome ?

• REduction of postural effects

• Joint protection

• Bracing and/or splinting

What interventions are appropriate for treating Myofascial restriction syndrome?

• Myofascial stretching

• Home stretching regimen

• Trigger point release

• Scar massage

What interventions are appropriate for treating Glenohumeral capsular restriction syndrome?

Joint mobilization

What interventions are appropriate for treating Lymphedema syndrome?

• Complete decongestive therapy

• Vasopneumatic pumping

Name the lymphoid organs

• Spleen

• Thymus

• Tonsils

• Bone marrow

• Lymph nodes

What are the functions of the lymphatic system?

• Initiate immune responses

• Filter lymph and blood

what makes lymph capillaries/initial lymphatics different than vascular capillaries?

Lymph capillaries/initial lymphatics are more permeable so they can absorb larger molecules of protein and fat

The following describes what lymphatic structure: single layer of overlapping flat endothelial cells that have anchoring filaments that attach them to the basement membrane

Lymph capillaries/initial lymphatics

What is the driving force of fluid in lymph capillaries/initial lymphatics?

Interstitial pressure

Name the structures of the lymphatic system from smallest to largest

Lymph capillaries → lymphatic pre-collectors → collectors → ducts → trunks

What is the function of lymphatic pre-collectors?

• Interstitial fluid absorption

• Fluid transportation

• Connection of the superficial and deep lymphatic systems

What are the layers of the lymph collectors?

• Intima

• Media

• Adventitia

What is the first lymphatic structure to have one way valves?

Lymph collectors

What is the segment between two valves in a lymph collector called? What is their purpose?

Lymphangion which is some smooth muscle that will contract when filled with fluid to push it forward

Roughly, how many lymph nodes do we have?

600-700

What is the function of lymph nodes?

• Filter fluid & remove waste products

• Allow fluid to cross watershed boundaries

• Start the immune response

Where are the major groups of lymph nodes?

• Axilla

• Inguinal

• Neck

• Abdomen

What happens to lymph nodes during acute infections?

• They be tender to touch

• Asymmetric

• Get enlarged

• Get matted together

• Can make the overlying skin red

What lymphatic structure drains into the subclavian vein?

Lymphatic ducts

What are the major lymphatic ducts? What regions of the body do they drain?

• Right lymphatic duct

  • Drains R UE, R half of chest, R side of neck and face

• Thoracic duct

  • Drains literally everything else

What is lymphatic fluid composed of? What composes the majority of it?

• Water (the majority)

• Protein

• Macrophages

• Waste products

How many L of lymph flows into the blood every day?

2 L

What law describes how the osmotic and hydrostatic pressures int he capillaries and interstitial tissue determine the direction of fluid movement?

Starlings Law of Equilibrium

What is lymphedema?

Chronic inflammatory condition that results from lymphatic insufficiency caused by a decrease in reabsorption or a decrease in transport capacity of the lymphatic system

When the lymphatic system is unable to accommodate for and reabsorbed an increase in lymphatic load, is that a dynamic or mechanical insufficiency?

Dynamic insufficiency

When the lymphatic system has a normal load but is unable to transport it, is that a dynamic or mechanical insufficiency?

Mechanical

What is primary lymphedema?

Lymphedema that is the result of a congenital defect that can be present at birth or develop later in a peep’s life

What is secondary lymphedema?

Lymphedema that is the result of acquired damage to the lymph vessels or nodes (surgery, radiation, trauma, tumor obstruction, CVI, infection)

What is Stemmer’s sign?

A thickening of the skin over the proximal phalanges of the toes or fingers of the involved limb and the inability to “tent”/pick up skin

What is the cause of lipedema?

A metabolic dysfunction

What makes lipedema different than lymphedema?

• No edema in the feet

• Edema is bilateral or quadrilateral

• Texture of the skin be soft and non-pitting

• Skin is cool in temp

• Skin is hypersensitive to light touch

• Peep can’t tolerate compression

Describe stage 0 of lymphedema

• Sub-clinical stage

• No edema be present but pt may report heaviness, tightness, or sensory changes in the involved limb(s)

• Reduced transport capacity (most commonly from surgery)

How long can stage 0 of lymphedema last?

Months - years

Describe stage 1 of lymphedema

• Pitting on pressure

• Reduction of swelling on elevation

• No clinical fibrosis

• Pt reports same stuff as last stage (heaviness, tightness, sensory changes, or pain in the limb)

Describe stage 2 of lymphedema

• Non-pitting cuz there’s so much fluid now that there’s nowhere for it to go

• Swelling does not reduce on evaluation

• clinical fibrosis present

• Positive steamer sign

• Higher likelihood of skin infection

Describe stage 3 of lymphedema

• Fat deposits in subcutaneous tissue

• Hair follicles are coarse or may not be present

• Skin folds

• Papillomas

• No pitting

• Positive steamer sign

• Pt be getting recurrent infections

• Skin looks leathery

What is lymphadenitis?

An infection of the lymph nodes by streptococcus or staphylococcus

What are the S/S of lymphadenitis?

• Swollen, tender, or hard lymph nodes

• Red, tender skin over lymph nodes

• Lymph nodes may feel rubbery if an abscess has formed

What is lymphangitis?

An infection of the lymph vessels that is a result of an acute streptococcal infection

What are the S/S of lymphangitis?

• Red streaks from the infected area to the armpit or groin

• Enlarged lymph nodes above the area of the red streaks

• Throbbing pain along affected area

• Fever of 100-104° F, chills, malaise, H/A, loss of appetite, and muscle aches

What is taken into consideration to reach a diagnosis of lymphedema?

• Pt history

• Systems review

• Inspection

• palpation

• Volume/girth measurements

What are some risk factors for developing lymphedema?

• Lymph node status (whatever that means)

• Radiation therapy

• Surgical complications

• Time since surgery

• Increased BMI

• Air travel without compression

• Inflammation/increased lymphatic load

• Decreased lymphatic return

• Being prone to scar tissue formation

Why are diuretics not helpful with lymphedema?

Cuz they don’t move the proteins in the lymph into the venous system

What is the purpose of a lymphoscintigraphy?

• ID sentinel lymph nodes Red

• Plan a biopsy or surgery

• ID points of blockage in the lymphatic system

The following describes what grade of pitting edema: slight depression that is hard to see

Grade 1

The following describes what grade of pitting edema: 0-0.6 cm depression that rebounds in less than 15 sec

Grade 2

The following describes what grade of pitting edema: 0.6-1.3 cm depression that rebounds in 15-30 seconds

Grade 3

The following describes what grade of pitting edema: 1.3-2.5 cm depression that rebounds in 30+ seconds

Grade 4