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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