Breast Cancer Flashcards
1
Q
Genetic Mutations: BRCA1 and BRCA2
A
- Associated with a high risk of
developing breast cancer and
ovarian cancer - Proteins produced from BRCA1 and BRCA2 –> involved in fixing damaged DNA
- Tumor suppressor genes
- Mutations in BRCA1 and BRCA2 impair DNA repair, allowing for damaging mutations to persist in DNA
2
Q
Tail of Spence
A
Lateral tissue projection into the axilla
3
Q
Level I Lymph Nodes
A
Lateral to the lateral border of the pectoralis minor muscle
4
Q
Level II Lymph Nodes
A
Behind pectoralis minor muscle
5
Q
Level III Nodes
A
medial to the medial border of the pectoralis minor muscle
6
Q
Goal of screening for breast cancer
A
facilitate early diagnosis, decrease breast cancer mortality
7
Q
NCCN Routine Screening Recommendations
A
- Clinical breast exam performed by a clinician every 1 to 3 years from ages 25 to 39 years
- Clinical breast exam and annual screening mammography beginning at age 40 –> Including evaluation of axillary and supraclavicular lymph nodes
8
Q
Breast Self- Exam
A
- No evidence on the effect of screening through BSE
- Empower women to take responsibility of own health
- Recommended to raise awareness among women at risk
9
Q
Mammography
A
- Low dose x-ray system to image the breast tissue
- Aids in early detection and diagnosis of breast cancer
- Typically involves two x-ray images of each breast (2D)
10
Q
3D imaging for Mammography (Breast Tomosynthesis)
A
- Earlier detection of small breast cancers
- Fewer unnecessary biopsies
- Improved likelihood of detecting multifocal cancers
- Clearer images of abnormalities within dense breast tissue
- Greater accuracy in pinpointing the size, shape and location of breast abnormalities
11
Q
Ultrasound
A
- Used to help diagnose breast lumps or other abnormalities found on mammogram or breast MRI
- Interpretation of results is highly operator dependent
- Cannot replace screening mammogram – unable to identify calcifications
12
Q
Indications for Ultrasound
A
- High-risk patients who are unable to undergo MRI
- Pregnant or unable to be exposed to x-rays
- Increased breast density
13
Q
Breast MRI
A
- Used as a supplemental tool to mammography or US
14
Q
Breast MRI Indications
A
- High risk for breast cancer
- Evaluation of extent of cancer following diagnosis –> Size and extent of cancer; Presence of multifocal cancers or cancers in opposite breast
- Evaluation of abnormalities seen on mammography
- Evaluation of lumpectomy sites in years following breast cancer treatment
- Following neoadjuvant chemotherapy
15
Q
Biopsy
A
- Standard technique for diagnosis of palpable and non palpable lesions
- Can occur by direct palpation in the office, under image guidance, or in the operating room
16
Q
Types of Biopsy
A
- Fine Needle Aspiration
- Core Needle Biopsy: Ultrasound-guided; MRI-guided
- Surgical: Excisional or Incisional
17
Q
Fine needle aspiration
A
- Simplest biopsy
- Small gauge needle is inserted into the palpable lump in an attempt to draw fluid out –> Quick way to distinguish between a fluid-filled cyst and a solid mass
18
Q
Core Needle Biopsy
A
- Employs a large gauge or larger cutting needle
that is passed through the abnormality and retrieves large cores of tissue - Titanium clip is commonly placed to mark the biopsy area
- Preferred method of diagnosis –> provides a tissue sample for definitive diagnosis and surgical planning
19
Q
Surgical Biopsy
A
- Required if CNB cannot be completed or if CNB results are considered discordant from the image findings
- Incisional biopsy: Portion of the mass is removed
- Excisional biopsy, wide local excision, or lumpectomy: Entire breast mass may be removed
20
Q
Ductal Carcinoma in Situ
A
- Heterogeneous, noninvasive breast lesion (Tis or Stage 0)
- Develops from epithelial cells lining the ducts
- Confined to the basement membrane, it lacks the
ability to metastasize - Considered to be a pre invasive lesion
- Tend to present as calcifications on mammogram
21
Q
Treatment of Ductal Carcinoma in Situ
A
- surgical excision with negative margins
- Lumpectomy +/- radiation and/or endocrine therapy
- Mastectomy alone
- Tamoxifen
22
Q
What is the most common form of invasive breast cancer
A
Invasive Ductal Carcinoma
23
Q
Invasive Ductal Carcinoma
A
- Originates in the duct, breaks through the duct wall and invades stromal tissue of the breast
- Further possible metastasis via lymphatic and/or circulatory system
24
Q
Invasive Lobular Carcinoma
A
- Grows through the wall of the lobule and may spread via lymphatic and/or circulatory system
- Tends to be more difficult to detect and multifocal
- Poorly imaged on mammogram; tumor
is often larger than what is seen on imaging
25
What is the 2nd most common type of invasive breast cancer?
Invasive Lobular Carcinoma
26
Paget's disease
* Rare form of ductal carcinoma
* Located beneath the nipple with itching, tingling, pain, eczema-like rash --> crusting, ulceration, and weeping
* Often occurs in conjunction with DCIS or invasive cancer
* May be dismissed at first as a
dermatological condition
27
Inflammatory Breast Cancer
- Rare form of ductal carcinoma
- Very aggressive, rapidly progressive form (not true inflammatory process)
* Cancer cells obstruct lymphatic vessels in the
breast --> erythema and edema
* Blockage occurs as a result of rapid increase in breast size
* Presents clinically as mastitis or cellulitis
* Carries a poor prognosis
28
Hormone Receptor positive
- Estrogen receptor positive
- progesterone receptor positive
29
HER2, Her2/neu, ERBB2
Test positive for human epidermal growth factor receptor 2
30
Triple Negative Breast Cancer
* Characterized by lack of expression of molecular target ER, PR, or ERBB2
* High risk of distant relapse in first 3 to 5 years following diagnosis
* Molecular pathophysiology remains poorly understood
31
Factors to determine type of surgery
* Type of tumor
* Reconstruction
* Size of tumor
* Overall health
* Size of breast
* Disease control
* Location in breast
* Cosmetic results
* Lymph node involvement
* Range of motion
* Involvement of other structures
* Complications
* Personal choice
32
Breast Conserving Surgery
* Excision of the tumor and a small portion of surrounding normal breast parenchyma to achieve negative margins
* Incision placement:
* Close to primary tumor – facilitate exposure of the tumor
* Cosmetic implications of scar location
33
Breast Conserving Surgery Indications and Contraindications
* Indications: early-stage breast cancer
* Contraindications: inflammatory breast cancer, multifocal breast cancer,
inability to receive radiation therapy
34
Total Mastectomy
* Removal of the skin, nipple and areolar complex and breast tissue including the pectoralis major fascia
35
Skin Sparing Mastectomy
* Small ellipse or oval of skin is removed incorporating the nipple and areolar complex
36
Nipple Sparing Mastectomy
* Dermis and epidermis of the nipple are preserved but the major ducts from within the nipple lumen are removed
37
Modified Radical Mastectomy
* Removal of breast tissue, fascia, nipple-areola complex, skin, and levels I and II axillary lymph nodes
38
Sentinel Lymph Node Biopsy
* Diagnostic procedure to assess lymph node status and to assess staging
* A radiolabeled isotope is injected around the cancerous tumor (or biopsy site)
* The dye flows through the ducts and the first node(s) it reaches are considered to
be the sentinel node
* Blue-stained sentinel nodes are removed (1-3 nodes)
39
Complications of Sentinel Node Biopsy
* Allergic reaction to blue dye
* Pneumothorax
* Sensory or motor nerve injury (rare)
* Lymphedema
* Surgical site infections
* Seroma --> Pocket of clear serous fluid that can develop after surgery
40
Axillary Lymph Node Dissection
* Removal of the tissue within the axillary basin including the
lymph nodes
* Typically involves levels I and II, in more advanced stages
level III
41
Complications of Axillary Lymph Node Dissection
* Neurovascular injury (Long thoracic nerve, Thoracodorsal neurovascular bundle, Intercostobrachial nerve)
* Hematoma
* Wound infection
* Seroma
* Brachial plexus neuropathy
* Lymphedema
* Axillary web syndrome
* Decreased range of motion
42
Breast reconstruction =
essential aspect of the overall post-mastectomy treatment
43
Breast reconstruction psychosocial impacts on patient well-being
* Improve outward appearance * Restore sense of femininity
* Improve overall self esteem/body image
44
Types of reconstruction surgical procedures
* Implant-based reconstruction
* Autologous tissue-based reconstruction
* Combination of implant and autologous-based reconstruction
45
Reconstruction procedure selection
* Availability of local, regional and distant donor tissues
* Size and shape of desired breasts
* Surgical risk
* Health of the tissue after mastectomy
* Patient preference
46
Implant- Based Reconstruction: Single-Stage direct to implant
* Best suited for patients with: Good preservation of skin after mastectomy or Small, non-ptotic breasts
* Implant positioned on the chest wall behind the pectoralis major muscle
* May require a breast lift on the contralateral side for aesthetic purposes
47
Implant-Based Reconstruction: Two Stage Tissue Expander/ Implant Reconstruction
* Tissue expander is positioned on the chest wall behind the pectoralis major and serratus anterior muscle or under the pectoralis major only
48
Implant Based Reconstruction Perioperative Complications
- Hematoma
- Seroma
- Infection
- Skin Flap Necrosis
- Impact exposure/extrusion
49
Late complications of implant-based reconstruction
- implant deflation or rupture
- Capsular contracure: scar tissue or capsule that normally forms around the implant tightens and squeezes the implant
- Rare: breast implant associated anapestic large cell lymphoma
50
Autologous Based Reconstruction
* Abdominal donor site is considered gold standard
* Options: Pedicled transverse rectus abdominis myocutaneous (TRAM) flap, Free TRAM flap, Deep inferior epigastric perforator (DIEP) flap
* Latissimus dorsi flap
51
Pedicled TRAM Flap Reconstruction
* Utilizes the rectus abdominis muscles to serve as the vascular carrier for lower abdominal skin and fat
- Low back pain and postural issues
52
Free TRAM Flap Reconstruction
* Portion of the rectus muscle and overlying tissue --> disconnected from the source of blood supply in the abdomen --> transferred to the chest --> vessels are anastamosed to internal mammary or thoracodorsal vessels
53
Deep Inferior Epigastric Perforator
* Perforating vessels of the deep inferior epigastric artery and vein dissected through the muscle and flap (fat and skin) is harvested with no muscle tissue
- Harvesting inguinal lymph nodes
54
Complications of Autologous- Based Reconstruction
* Total or partial flap loss
* Hematoma
* Hernia
* Delayed wound healing
* Infections
* Fat necrosis
* Contour irregularities
55
Combined Autologous Tissue/Implant Reconstruction
* Latissimus dorsi myocutaneous flap:
- Indicated for patients with thin, contracted or previously irradiated skin
- Flap provides additional skin, soft tissue and muscle
- Permanent implant is placed beneath the flap to provide adequate breast volume --> Tissue expansion may be required prior to the flap procedure
56
Complications of Surgery and Reconstruction
Wound infection/Non-healing wounds
* Post-op pain
* Scar adhesions
* Decreased ROM/Loss of function
* Necrosis of skin
* Weakness
* Seroma formation
* Axillary web syndrome
* Changes in chest wall or breast tissue sensation
* Disfigurement
* Phantom breast syndrome
* Loss of function
* Nerve injury (long thoracic: Scapular winging, thoracodorsal: Tiredness of UE, intercostobrachial: loss of decreased sensation to arm or axilla)
* Fatigue
* Capsular contraction
* Lymphedema
57
PT After Breast Reconstruction
* Focus – protecting the integrity of the reconstructive technique and returning patient to full functional mobility
* After all reconstruction, limited lifting/carrying with affected UE (generally a gallon of milk or less)
* After autologous reconstructions – limit trunk flexion for 6 weeks post- operatively, little to no trunk strengthening for 6 months
* Patients typically have difficulty maintaining upright posture
* After implant-based, shoulder ROM and chest wall flexibility
58
What are antineoplastic agents based on?
Risk of recurrence after surgery
* Invasive cancer
* Positive lymph node findings
* Large tumors
* Pre-menopausal patients
* Aggressive tumors
59
Antineoplastic Agents Include
* Chemotherapy
* Endocrine/Hormonal therapy (Used with hormone receptor positive tumors (ER, PR
or both))
* Targeted therapy
60
The selection of therapy is determined by...
biological features of the cancer
61
Goal of chemotherapy
* Interrupt the cell cycle resulting in cell death
* Prevent cancer from spreading to other parts of the body
* Slow growth rate of cancer
* Relieve symptoms of cancer
62
Anthracyclines Side Effects
* Early (within 1 week of administration): pain at infusion site, nausea and
vomiting, urine may appear red in color
* Later (within 2 weeks after treatment begins): low blood counts, hair loss, darkening of the nail beds
* Serious but uncommon side effect: heart disease
63
Predictors of anthracycline- induced cardiotoxicity
* Cumulative dose
* Age > 70 years
* Prior irradiation
* Concomitant administration of other chemotherapeutic agents
* Concurrent chest radiation
* Underlying heart disease
64
Taxanes Side Effects
* Common: low blood counts, hair loss, arthralgias and myalgias, peripheral
neuropathy, nausea, vomiting, and diarrhea, mouth sores, hypersensitivity reaction
* Less common: edema in feet and ankles, decreased liver function, low BP, radiation recall, changes in nail structure
- Cardiotoxicity
- Neurotoxicity
65
When is there an increased risk for cardio toxicity
when taxanes are combines with anthracyclines
66
Neurotoxicity from Taxanes
CIPN
* Taxane-induced motor and sensory neuropathies --> cumulative and dose and
schedule dependent
* Sensory neuropathy: burning, paresthesias of the hands and feet and loss of reflexes
* Motor neuropathy: predominantly affects distal muscles
67
Alkylating Agents Side Effects
Low blood counts, hair loss, nausea and vomiting, loss of
fertility, discoloration of nails
68
Cyclophosphamide Risks
Cardiotoxicity
Pulmonary Toxicity
69
Cardiotoxicity from Cyclophosphamides
* Associated with acute cardiomyopathy
* Other complications include hemorrhagic myopericarditis --> pericardial effusions, tamponade and potentially death, typically within the 1st week of treatment
70
Pulmonary Toxicity from Cyclophosphamides
* Rare, but risk increases with concomitant administration of radiation or drugs with potential pulmonary toxicity
* Patterns: acute pneumonitis that occurs early in treatment; chronic, progressive, fibrotic process that may occur after prolonged therapy
71
Platinum Agents Side Effects
* Nausea and vomiting
* Low blood counts
* Kidney toxicity
* Ototoxicity
* Neurotoxicity
72
What does Cisplastin Cause?
* Neurotoxicity
* Axonal neuropathy that predominantly affects large myelinated sensory fibers
with damage occurring at the dorsal root ganglion and peripheral nerves
* Subacute development of numbness, paresthesias and occasionally pain – begins
in toes and fingers and spreads proximally to legs and arms * Impairment in proprioception and loss of reflexes; pinprick, temperature sensations
and power are usually spared
* Cessation of cisplatin use eventually results in improvement of neuropathy –
recovery is often incomplete
73
What is targeted therapy
* Agents designed to target small molecules that drive cancer proliferation * Less likely to cause profound myelosuppression secondary to the mechanisms for inducing cell death
74
Trastuzumab
* Used to treat cancers that are HER2/neu positive (HER2+) --> Defective growth-promoting oncogene
* May slow or stop the growth of breast cancer by targeting the HER2/neu receptors; may also facilitate the immune system in the destruction of cancer cells
* Side effects: left ventricular dysfunction, congestive heart failure
75
Hormone Therapy
* Refers to the use of drugs in the treatment of estrogen receptor positive (ER+)
breast cancers
* Typically taken for 5+ years to decrease risk of recurrence or cancer in the
contralateral breast
* Can be used neoadjuvantly to reduce the tumor size or for chemoprevention in individuals at high risk of breast cancer
76
MOA of Hormone Therapy
* Lower the amount of available estrogen
* Block estrogen’s action on cancer cells
77
Hormone Therapy: Selective Estrogen Receptor Modulator
- Tamoxifen
- Blocks effects of estrogen
- Side effects: Increased risk of endometrial cancer, stroke, DVT, pulmonary embolism, hot flashes, fatigue, weight gain, premature menopause
78
Hormone Therapy: Aromatase Inhibitors
* Interfere with the production of estrogen in postmenopausal women by blocking the enzyme aromatase
* Aromatase converts the hormone androgen into small amounts of estrogen in the body
79
Aromatase Inhibitors Side Effects
* Arthralgias and myalgias – bilateral symmetrical pain/soreness in the hands, knees, hips, lower back,
shoulders and/or feet
* Early morning stiffness and difficulty sleeping
* Cardiac issues, osteoporosis
* Menopause-type symptoms – hot flashes, vaginal dryness, night sweats
* Cognitive dysfunction
80
Adjuvant Whole-Breast Radiation Therapy
significantly reduces the risk of ipsilateral breast tumor recurrence after breast conservation
81
Post-mastectomy radiation
reduce the risk of focal recurrence in the scar after surgery
* Large tumors (>5cm), 4 or more (+) lymph nodes, tumor close to the rib cage/chest
wall, skin involvement
82
What is the standard of care for patients with invasive carcinoma
radiation therapy
83
what is the goal of radiation therapy
eradicate any residual cancer cells in the affected breast or adjacent lymph nodes
84
Radiation Dosage
* Whole-breast radiation delivered daily (M-F)
for 5-7 weeks using a linear accelerator machine
* A later “boost” may be added to target the tumor site or surgical incision
85
Radiation Dosage Effects
* 40 Gy+ = effects on the skin
* 50 Gy+ - effects on the bone
* 60 Gy+ - effects on the soft tissue (fascia)
* 70 Gy+ - effects on the muscle and tendon
86
Side Effects of Radiation
* Skin reactions: Redness, Burns
* Cardiovascular dysfunction
* Capsular contraction of implant
* Malignancy
* Infection
* Delayed wound healing
* CNS effects
* Radiation fibrosis
* Brachial plexopathy
* Fatigue
* Radionecrosis of the bone
* Anorexia/Weight loss
* Immunosuppression
* Diarrhea
* Pain
* Lymphedema
* Cancer Related Fatigue
87
Breast Cancer Treatment options
* Surgery --> +/- hormone therapy
* Surgery --> radiation --> +/- hormone therapy
* Surgery --> chemotherapy --> radiation --> +/- hormone therapy
* Chemotherapy --> surgery --> radiation --> +/- hormone therapy
88
5 Phases of cancer
- Staging/pretreatment
- Primary treatment
- Post treatment
- Recurrence
- End of life
89
Staging/Pretreatment
- Symptoms: anxiety, pain, functional loss
- Education about functional impact of treatment
90
Primary treatment
- Pain, anxiety, decreased mobility, wound care, mild edema, decreased strength
- Education about prevention of loss of function, lymphedema management, ROM, strengthening, pain management, relaxation/sleep hygiene
91
Post-Treatment
- Mobility, edema, weakness, reconditioning, weight gain, +/- pain
- Exercise to improve strength, endurance, possible lymphedema management, nutrition/ weight control
92
Recurrence
- See primary treatment; possible bony metastatic disease; central nervous system/other system involvement, fatigue
- see primary treatment; orthotics; ADs; aerobic exercise
93
End of life
- Fatigue, decreased mobility, possible dependence in self care
- support, leisure, counseling
94
Patient Eval - Cancer History
- Date and means of diagnosis
- Staging and grade of tumor
- surgical procedures and complications
- other treatments (adjuvant or neoadjuvant chemo, radiation, hormonal, immunotherapy)
95
Patient Evaluation
* Patient Reported Functional Outcome Measures
* Red flags
* Pain history
* Functional assessment/Physical examination
96
Signs of cancer recurrence
palpable lymphadenopathy, malignant appearing skin lesions, bony tenderness
97
Functional Outcome Measures
* Functional Assessment of Cancer Therapy – Breast Cancer (FACT-B)
* FACT-B+4
* Brief Fatigue Inventory
* Disability of Arm, Shoulder and Hand (DASH)
98
Functional Assessment of Cancer Therapy - Breast Cancer
* Self-report measure that encompasses physical, social, emotional and functional
well-being for patients diagnosed with breast cancer
99
FACT - B + 4
* Comprised of the FACT-B plus a 4-item Arm Morbidity subscale to assess the impact
of lymphedema on HRQOL
100
Brief Fatigue Inventory
* Assess the severity of fatigue and the impact of fatigue on daily functioning
101
Acute (Diagnosis to 1 year)
- Frequency of visits: 1-2 days following drain removal
- Repeat baseline measures
- Monitor: lymphedema, HEP, AROM, Strength, Activity/Vocation/Recreation
102
Recurrence/ Relapse (1-5 years)
- Frequency: 6 mo - year
- Repeat baseline measures
- Monitor: lymphedema, HEP, AROM, Strength, Activity/Vocation/Recreation
103
No Evidence of Disease ( >5 years without recurrence)
follow up visits as needed 1, 3, 6, 9, 12 mo
104
End of life
Palliative care to promote function, pain control
105
Focus of rehabilitation intervention
* Soft tissue fibrosis
* Deficits in muscular strength and flexibility
* Lymphatic insufficiency
* Muscle hypertonicity
* Neural hypersensitivity
106
Cardiac Dysfunction
* Cardiotoxicity = potential side effect of chemotherapy and radiation treatments
* VO2 max diminishes rapidly across all stages of cancer survivorship --> VO2 max decreases in survivors of breast cancers equivalent to 2 to 3 decades of aging (typically decreases ~10% per decade)
107
What is the most common way to assess cardiac function
Resting echocardiographic measurement of left ventricular ejection fraction
-- Not sensitive enough to detect early chemotherapy- related cardiomyopathy
108
Risk factors of coronary artery disease
* Radiation Therapy
* Decreased physical activity
* Excess weight
* Sleep disturbance
* Hormonal suppression
109
Radiation therapy risk for CAD
* Increases risk for cardiac injury and accelerated CAD if the radiation field targeted lung, breast, esophagus or mediastinal tumor
* Mechanism:
* Microcirculatory damage accelerating atherosclerosis
* Increase risk of clotting secondary to the fibrin deposition that occurs as a side effect of treatment
110
Anthracycline Induced Cardiomyopathy
- Dose Dependent (recovers when medication is discontinues)
- Affects RIGHT ventricle
- Some pts have permanent loss of cardiac function
- Early or late onset
111
Pathophysiology of anthracycline-induced cardiomyopathy
asymptomatic decline in ejection fraction in first months following treatment --> progressing to symptomatic heart failure with potential fatal cardiac event
112
Aerobic exercise has the ability to:
* Modulate oxidative stress
* Mitigate multiple causes of myocardial damage – ischemia-reperfusion,
diabetes, aging
* Reduce the cardiotoxic nature of the drug
113
Ischemia- Reperfusion Injury or deoxygenation injury
Tissue damage caused when blood supply returns to tissue after a period of ischemia
114
Risk factors for aromatase inhibitor induced musculoskeletal symptoms
- 6 to 8 weeks after starting
* Anxiety
* Depression
* High BMI
* Prior hormone replacement
* History of OA or arthralgias
* Poor QOL at initiation of treatment
* Longer menopause
115
Major criteria for AIMSS diagnosis
- Currently taking an AI
- Joint pain has developed or worsened since taking AI
- Joint pain improves or resolves after 2 weeks of stopping AI
- Joint pain returns upon resuming AI
116
Minor criteria for AIMSS diagnosis
- symmetrical joint pain
- pain in hands and/or wrists
- carpal tunnel syndrome
- decreased grip strength
- morning stiffness
- improvement in joint discomfort with use of exercise
117
how many criteria points do pts have to meet to qualify for AIMSS diagnosis
all major criteria and 3 minor criteria
118
Pathophysiology of AIMSS
– estrogen deprivation can lead to:
* Chondrotoxicity --> MSK symptoms
* Loss of cartilage
* Decreased pain thresholds and increased circulating inflammatory cytokines
119
How to treat focal symptoms of AIMSS
* Referral to specialist – i.e. hand therapist (PT or OT)
* Therapeutic exercise – treat based on the symptom burden
* Anti-inflammatories
* Corticosteroid injections
120
How to treat diffuse symptoms of AIMSS
- Whole boy treatment (treating the underlying cause!)
* Aerobic activity and strength training per ACSM guidelines
* Yoga
* Aquatic exercise
121
Upper quadrant impairment
* Commonly reported in individuals receiving treatment for breast cancer
* Most common complaints = pain and weakness in involved extremity
* Most patients will present with more than one symptom
* Arm and/or breast edema, shoulder stiffness, weakness, movement impairment, axillary and/or chest wall pain, sensory changes
122
Upper Quadrant impairment - shoulder girdle movement
- impacted by surgery and/or radiation
* Limited shoulder abduction and external rotation
* Altered movement patterns of the scapula
* Loss of motor activity – may alter force couple produced by muscles of rotator
cuff --> increasing upward rotation of scapula = impingement syndrome and glenohuromeral instability
- Limited ROM (potential for frozen shoulder)
123
Adhesive capsulitis/ impingement PT management
* Shoulder mobilization - can begin as soon as the drains are removed
* Capsular tightness and dysfunction can go unnoticed until RT prep
* Wall walks, pendulums, AAROM in all planes, PROM in all planes with scapular
stabilization, gentle resistive exercises, etc
124
Pectoral Dysfunction - surgery
* Pectorals --> hypertonic 2º to pain-induced contraction (guarding) resulting in
thoracic flexion and scapular protraction
125
Pectoral dysfunction - radiation fibrosis
causes further tightness of pec tendons and muscle sheaths
126
Pectoral dysfunction - reconstruction
* Pec major incorporated into muscular pouch holding the implant
* Muscle tension markedly increases pulling scapula anteriorly
127
other causes of pectoral dysfunction
pain
anxiety
tight shoulder capsule
128
PT management of pectoral dysfunction
* Trigger point release
* Gentle, repeated stretching of involved muscle groups
* Postural re-education
* Range of motion
129
Radiation Fibrosis
* Radiation injury can present as late effects, months or years following completion of RT – NOT REVERSIBLE
* Can occur anywhere in the radiation field
130
What is radiation fibrosis
that occurs in response to radiation
* Inflammation in the radiation field = evolves into a fibrotic process characterized by abnormal collagen deposition, poor vascularity and scarring
131
Radiation fibrosis syndrome
* “The gift that keeps on giving” * Effect of RF with respect to skin, muscle, ligament,
tendon, nerve, viscera and bone that underlies the
neuromuscular and musculoskeletal complications
or RFS
* Symptoms can change often
132
radiation fibrosis syndrome neuromuscular effects
* Primary clinical effects of RFS-induced nerve dysfunction = pain, sensory loss
and weakness --> functional deficits and decreased QOL
133
neuropathic pain from RFS
* Severe and out of proportion to perceived pathology
* Results from damage to the nerve root, plexus and/or peripheral nerve
134
weakness from RFS
* Caused by damage to any structure (spinal cord, nerve root, peripheral nerve)
* Damage to brachial plexus – most common cause of radiation related weakness
* Direct RT effects on muscle = weakness
135
RFS effects on muscle tissue
* Progressive fibrosis in muscle fibers within the field
can cause focal myopathy
* Myopathic muscles = weak relative to normal muscle, prone to painful spasms
* Pain associated with muscle spasms – similar to pain that is associated with myofascial trigger points
136
TRFS effects on tendons and ligaments
Progressive fibrosis with subsequent loss of
elasticity, shortening and contracture --> leading to progressive and marked loss of ROM and function
137
Axillary Web syndrome
* AKA axillary cording or lymphatic cording
* Common complication following axillary
node dissection or sentinel node biopsy
* Visible and palpable web or fibrous cord of subcutaneous tissue that may be confined to
the axilla or extend distally along the anterior, medial aspect of the arm as far as the palm
138
what is it called when axillary web syndrome extends into the area of the breast
Mondor's Syndrome
139
mechanism of AWS
* unknown
* May occur from lymphatic disruption after surgery or disruption of fascial planes during surgery
* May be attributed to lymphovenous injury or lymphatic flow obstruction from prolonged positioning during surgery
* Biopsy of cords = sclerosed and thrombosed lymphatics
140
AWS cords
most visible in the axilla when shoulder is abducted or in antecubital space when elbow is extended
141
common symptoms of AWS
radiating pain down
the arm during shoulder flexion and abduction, limitation of shoulder abduction and/or elbow extension
142
PT intervention of AWS
* Myofascial release
* Soft-tissue mobilization
* Skin traction
* Cord bending
* Scar tissue mobilization
- 4 to 18 weeks
- ROM typically regained within 2 mo of PT
143
Radiation induced brachial plexopathy
* Painless weakness within initial impact on the upper
trunk, can progress to involve the entire plexus
* Delay in onset for more than 6 months after radiation therapy
* Flaccid, nonfunctional arm with profound lymphedema
144
Radiation induced brachial plexopathy diagnosis
clinical, based on onset, progression, and identification of concurrent lymphedema; MRI and electrodiagnostic studies
145
management of radiation induced brachial plexopathy
* Primarily supportive
* Management and control of lymphedema
* Stabilizing and maintaining function of shoulder girdle --> Used to assist in ADLs and Shoulder support to avoid shoulder subluxation
146
prognosis for radiation induced brachial plexopathy
poor
147
cancer related fatigue
* An unusual, persistent, subjective sense of tiredness related to cancer or cancer
treatment that interferes with usual functioning
* Likely the result of many causes
148
CRF diagnostic criteria
* Period of 2 weeks or longer within the preceding month during which significant CRF or
diminished energy was experienced each day along with additional CRF-related symptoms
* Results in significant distress or impairment of function
* Clinical evidence suggesting CRF = consequence of cancer or cancer therapy
* CRF is not primarily a consequence of a concurrent psychiatric condition (major depression)
149
Physiological Contributors to CRF
- muscular strength
- muscular endurance
- CP fitness
- Body composition
- inflammatory process
- metabolic function
- endocrine function
- immune function
150
medical contributors to CRF
anemia
thyroid
151
psychological contributors to CRF
pain
mood
distress
cognition
152
behavioral contributors to CRF
sleep
appetite
153
Social contributors to CRF
social interaction
positive reinforcement
154
pharmacological interventions to CRF
* Hematopoietic stimulants – treat anemia
* Hormone replacement - thyroid
* Sleep medication
* Psychostimulants
155
Nonpharmacological interventions to CRF
- EXERCISE
* Aerobic, resistance, multimodal with higher intensity
* Timing: safe and effective during treatment, post-treatment and survivorship
156
General principles for exercise for CRF
* 60% to 85% of maximal HR
* At least 30 minutes, 3 times per week working up to a least 150 minutes of moderate
or 75 minutes of vigorous activity (ACSM guidelines for patients with cancer)
157
are there clinical manifestations of osteoporosis
not typically
until there is a fracture
158
osteoporosis from cancer treatment
rapid and severe bone loss secondary to iatrogenic induction of a hypogonadal state Other treatment related factors that can lead to bone loss:
* Chronic opiate therapy
* Bone marrow transplant
* Chronic corticosteroid treatment
* Chemotherapy-induced bone cell toxicity
159
Pt mangement for osteoporosis
* Weight-bearing and resistance exercises to preserve or increase bone strength
* Balance training and fall prevention to minimize fall and fracture risk
* Postural retraining, body mechanics and positioning
160
CIPN
Common, potentially debilitating and dose-limiting side effect of cancer
treatment that may occur when chemotherapeutic agents damage the
peripheral nerves
161
symptoms of CPIN
* Begin in the hands and feet and move proximally
* Pain, burning, tingling, numbness, electric shock, pins and needles, temperature
sensitivity
* Affect ADLs and QoL
* Can persist months to years after completion of chemotherapy
162
CIPN Clinical manifestation
- deficits in sensory, motor and/or autonomic dysfunctions
- sensory symptoms develop first
- motor symptoms develop second
163
Pt management of CIPN
* Balance training * Strength training * Interactive sensory-based activities * Endurance training
164
outcomes of PT for CIPN
improved static and dynamic balance, reduction in CIPN
symptoms, decreased postural sway, increased QOL, decreased pain, increased lower extremity strength, improved TUG and BBT
165
post mastectomy pain syndrome
Persistent neuropathic pain disorder that can occur following any breast
surgery
166
what is post mastectomy pain syndrome caused by
* Caused by direct nerve injury (severance, compression, ischemia, stretching,
and retraction) during surgery or subsequent formation of a traumatic neuroma or scar tissue
167
symptoms of post mastectomy pain syndrome
* Pain localized to anterior/lateral chest wall, axilla and/or medial upper arm
* Burning, tingling, shooting, stinging or stabbing pains and hyperesthesias
* Persists > 3 months after surgery
168
How is post mastectomy pain syndrome diagnosed
Based on characteristic symptoms
* Detailed sensory and motor neurologic evaluation of the affected sites reveals
motor and/or sensory deficiencies of affected peripheral nerve
169
3 ways to manage PMPS
- pharmacologic (antidepressants and anti epileptics)
- surgical (neuroma, scar tissue release)
- regional nerve block
170
physical therapy for PMPS
* Restoring joint mobility and preventing tendon shortening with passive mobilization
techniques
* Reducing pain with myofascial release and sustained trigger point compression
* Addressing tight muscles with manual stretching and transverse strain
* Strengthening shoulder girdle muscles with active and/or active-assisted
mobilization
* Desensitization techniques
- guided imagery, acupuncture, biofeedback
171
phantom breast pain
* Disturbing and painful sensations in the area of the nipple alone or involving the entire breast or resected segment
* Similar to those that occur after a limb amputation
* Symptoms are similar to PMPS but are limited to the region of the amputated breast
172
management of phantom breast pain
desensitization techniques
173
risk factors for lymphedema
* Extent of axillary dissection
* Axillary radiation after surgery
* Type of breast surgery
* Adjuvant and neoadjuvant chemotherapy
* Presence of infection in ipsilateral UE
* Increased BMI
* Hypertension
174
lymphedema management
* Complete decongestive therapy - Most common treatment for lymphedema
* Currently recognized as the “gold standard” of care of lymphedema
* 2 phases (intensive phase, maintenance phase)
175
intensive phase of complete decongestive therapy
* Goal: maximum volume reduction and normalization of tissue texture
* Consists of manual lymphatic drainage (MLD), compression bandaging, patient education, skin care and exercise
176
maintenance phase of complete decongestive therapy
* Goal: maintain volume reduction that was achieved in the intensive phase
* Consists of compression garment fitting, exercise, self MLD, possible maintenance MLD by a qualified provider, skin care, and instruction in self care
