Breast CA & Lymphedema Flashcards
Cancer Warning Signs
C: Changes in bowel & bladder
A: a sore that does not heal
U: unusual bleeding or discharge
T: thickening of lump in breast or elsewhere
I: Indigestion or difficulty in swallowing
O: obvious change in wart/mole
N: nagging cough or hoarseness
Signs of Breast CA
New lump or mass, breast swelling, skin irritation or dimpling, breast or nipple pain,nipple retraction, redness/scaliness/thickening of nipple or skin, nipple discharge
Sentinal Lymph Node Biopsy
Preferred to axillary lymph node dissection; indicated for ductal carcinoma in situ; radioactive dye is injected in breast (subareolar, peritumoral, intradermal or intraparenchymal); 1-3 nodes are dissected and tested for mets.
Axillary lymph node dissection (ALND) Procedure
used to be the standard; Level 1 (lat to pec minor) and 2 (beneath pec minor) extraction; level 3 (medial to pec minor) only removed if suspicious.
ALND Risks
Long thoracic nerve (winged scapula 2/2 serratus anterior), Thoracodorsal nerve (disrupts brachial IR and ABD above 90 deg), medial and lateral pectoral nerves, Intercostobrachial nerves (numbness of inner arm);
Also–brachial plexus injury, nerve damage and lymphedema, cutaneous numbness, pain, infection, seroma, axillary webbing
Lumpectomy
Tumor removal with 1 cm margin for stage 1 & 2 breast invasive carcinoma (Contraindicated in radiation has occurred). Can be guided by palpation, wire, radioactive seed. 2 mm or greater is successful.
Mastectomy Indications
Radical procedure, performed if large or multifocal tumor, local recurrence after tx;
Mastectomy Complications
Lymphedema, reoccurrance, infection, skin-flap necrosis, “dog-ears,” Seroma, Hematoma, Fibrosis
Modified radical mastectomy
breast tissue + pec fascia + ALND
Skin-sparing mastectomy and nipple-sparing mastecotmy
presearve breast skin and outline of the inframammary fold; allows for immediate reconstruction;
Candidates: prophylactic mastectomy, early stage breast CA
Extended radical (Halstead) mastectomy
only proposed for a tumor that involved pec major; breast tissue, pec major and ANLD and internal mammary lymph node dissection
Contralateral Prophylactic Mastectomy
contraversial; risk is only 3-7%; should not be done if pt has locally advanced breast CA
Types of Implants
Inflatable with silicone envelope and valve for saline filling; gell-filled with set volume & shape; expanders
Complications of Implants
Capsular contracture, implant loss, glandular defects, scar retractions, nipple areola complex (NAC) dislocation
Capsular Contracture
(6-12 mo delay, fibroblastic capsule around implant, increases after radiotherapy; sx if severe for surgical capsulotomy; polyurethane coating and textured envelopes help to avoid contracture
Latissimus Dorsi Flap (LDF)
Indication: Pec mm affected by radiation and can’t be used to secure implant; Lat is excised and rotated below axilla to fix the implant; Tissue from abdomen is harvested to recontruct breast tissue
(+) safe blood supply, surgical time and rehab short
(-) Back scar, lat tendon cut to avoid bulge, shoulder function
Transverse Rectus Abdominus Flap (TRAM)
Indication: sufficient tissue of lower abdomen; tissue taken from under umbilicus with resection. blood from sup epigastric.
(+) autologous, natural shape, decreased need for contralateral re-shaping;tummy tuck
(-) surgical time 4-5 hrs, recovery 6-8 weeks (6 days in hospital), mesh required to reinforce abdominal wall, decreased abdominal strength
“Free Flaps” aka Microsurgical techniques
transfers tissue from abdominal, inner thigh or gluteal areas to create breast
Free TRAM technique
small portion of rectus around umbilicus is harvested where inf epigastric is located; flap taken to chest wall and anastomosed with thoracodorsal vessel;
(+) improves blood supply, decreased abdominal mm loss, infepigastric better than superior for harvesting; preferred with pts who have had radiation.
(-) flap failure
DIEP flap; aka perforator flap
skin island by deep inferior epigastric perforator vessel is harvested; preferred to TRAM but must be large enough mm; RA is spared but risk of vascular thrombosis and loss of flap
SIEA: Superior Inferior Epigastric Artery flap
blood supply harvested from abdominal fatty tissue; spares mm, preferred to DIEP, decreased post op time. Difficult to find an SIEA with enough blood flow
Gluteal Artery perforator flap
skin and fat harvested within pantyline; indicated for thin women with inadequate abdominal adipose; no loss of tissue, no functional loss, concealed scar
gracilis flap
gracilis harvested to create B-cup if not enough adipose on abdomen or back; Commonly harvested with reported minimal consequence
Microsurgical Breast Reconstruction Recovery
6-8 hrs of surgery with anesthesia
3 weeks no driving
8 weeks no lifting> 5 lbs
PT after expanders & final implant
2 weeks post-op: limited ROM
2+ weeks: progress to normal activity with ROM
Final implant: limited ROM x 1 week; progress after to full ROM
PT after Flap Procedures (LDF, TRAM, Microsurgery)
LDF: Week 2-3: Drans intact and overuse of arms contraindicated 2/2 seroma
TRAM: no heavy lifting; At 8 weeks begin STM, stretching, MFR–common to feel tight and stiff; may have abdominal pain up to 2 years post-op
Microsurgery: No pressure on operative side for 2 mo! Avoid prone or SL on side of repair; No garments or bras.
Cellulitis (signs, sxs, tx)
S/s: Rubor, warmth, tenderness, flu-like sxs, fever, swollen lymph nodes;
Dx by placing pt in supine and seeing if it resolves (may be disrupted lymphatics post-op)
Tx: mild with antibiotics orally, severe with parenteral antibiotics
Flap Necrosis
death of surgically excised mm, fat, skin 2/2 poor blood supply; will require office debridement or surgical excision
Dehiscence
split in incision line which results in open surgical wound
Seroma
pocket of serous fluid at surgical site (usually near axilla); prevent with closed suction drains.
Small seroma is advantageous and reduces risk of breast concavity
May require decompression
Pneumothorax
accumulated air in pleural space/collapsed lung;
s/s: SOB, crepitus
Cause: excision via wire localization of lesion, deep dissection of the intercostals region
Tx: reinflation of lung with chest tube or aspiration with catheter
Brachial Plexopathy
damage to brachial plexus
S/s: altered sensation, decreased strength and ROM in arm and hand; differentially dx intercostal brachial nerve injury–caused by poor positioning during operation; early intervention helps
Axillary web syndrome
formation of taught cords in axilla extending from chest wall to UE–wrist
Cause: ALND and SLND; common 2/2 lymphatic and venous disruption in axillary region;
S/s: pain with insious onset, decreased ROM in flexion and abduction
Tx: Early intervention, antiinflammatories
Risk factors for Lymphedema
Axillary dissection, Mastectomy, Radiation of breast/chest wall & nodes
Maybe higher BMI, AA, increased age, lower UE function, sedentary behavior
Precautions for exercise while patient is undergoing Chemo or radiation
Goal to maintain PA; decrease intensity and duration;
Anemia: delay exercise
Severe fatigue: 10 min light exercise daily
Radiation: avoid Chlorine
Osteoporosis: avoid trunk flexion
PN: stationary bike over treadmill
Avoid gyms and public pools 2/2 decreased immune function
Types of Lymphedema
Acute: less than 5 mo: 60%
Chronic/Progressive: 30-40%
Fluctuating: 15-22%
** Mild are 3x more likely to have mod-sev
Objective Measures of Lymphedema
Bioimpedance spectroscopy: observes presence of extracellular fluid
water displacement
perometry
circumferential measures
circumferential measures converted to volume measures
Surgical tx of Lymphedema
Debaulking procedures, microsurgery, lymphatic-venous anastomosis;
- Consider when conservative tx has failed, chronic & pitting; need for compression garments will continue after tx.
Medications for lymphedema
Benzopyrones
Selenium compounds
pentoxifylline (imprved blood flow in vessels)
Vit E (skin care)
