Cancer-Related Lymphedema Flashcards
How many women with breast cancer will develop Lymphedema within the 1st 3 years?
1 in 5 women
What percent of people with head and neck cancer will develop Lymphedema within the 1st 18 months?
90%
What percent of women treated for gynecological cancer will develop Lymphedema within the 1st 12 months
37%
What percent of men with prostate cancer will develop Lymphedema after radical prostatectomy?
20.8%
According to the NIH, What percent of people with head and neck cancer will get Lymphedema?
90%
Lymphedema can cause _____________ internally and externally
Swelling
Internal effects of Lymphedema
changes to voice, difficulty swallowing, difficulty breathing, and changes to vision
External effects of Lymphedema
reduced cervical ROM, dysfunction of the arm and shoulder including shoulder misalignment, head tilt, and postural deviation
Radiation treatments for head and neck cancer can cause fibrosis and scarring up to ____________ after treatments have ended, and this can lead to ____________________________
capsulitis, tendonitis, dystonia, spasms, weakness, and contractures
What are the two main contributing factors to developing Lymphedema with Gynecological cancers?
Lymphadenectomy and radiation therapy
Cervical cancer typically involves ______________ and __________________ with a _____% prevalence of Lymphedema
radical hysterectomy, pelvic lymphadectomy; 10-41
Those with Endometrial cancer have higher risk factors of pre-morbid Lymphedema including _________ and ________ with ______% prevalence of Lymphedema
obesity and CVI; 1.2-47%
Ovarian Cancer has what prevalence of Lymphedema?
4.7 - 30.4%
What percent prevalence does Vulvar cancer have of Lymphedema?
10-73%
For those with prostate cancer, the prevalence of lower limb Lymphedema is _________% and genital Lymphedema _____% after radical prostatectomy with pelvic lymph node dissection; with addition of radiation of the pelvic lymph nodes after dissections, increase in Lymphedema prevalence significantly increases to ___________% of the lower limbs and ___________% of the genitals
0-14%, 0-1%, 18-29%, and 2-22%
With colorectal cancers, what is the prevalence of lower limb Lymphedema?
31.4%
What functions do truncal and LE Lymphedema impact?
ADLs, AROM, Mobility, Proprioception, Balance, and Skin Hygeine
________ women who are diagnosed with breast cancer will develop Lymphedema; Based on breast cancer stats from ACS, this means over ____________ women a year could develop Lymphedema
1 in 5, 70,000
In 2024, it’s estimated that there will be ______________ new cases of Invasive Breast Cancer Diagnoses
310,720
In 2024, it’s estimated that there will be _________________ new cases of Ductal Carcinoma in Situ (DCIS)
56,500
In 2-24, it is estimated that _______ women will die from breast cancer
42,250
What is the most common cancer in women in the US? and it makes up _____% of all new female cancers
Breast; 30
What is the median age at diagnosis of Breast Cancer?
62
Breast cancer incidence rates have increased by _______% per year
0.5
Breast cancer is the __________________ cause of cancer death in women
second leading
Breast Cancer death rates have decreased by how much between 1989 and 2020?
43%
How many breast cancer survivors are in the US
3.8 million
Risk factors for breast cancer
age, genetic mutations, reproductive history (mensuration before age 12, menopause after age 55), having dense breasts, history of breast cancer or certain non-cancerous breast diseases, family history of breast or ovarian cancers, previous treatment using radiation therapy, not being physically active, being overweight or obesity after menopause, taking hormones, reproductive history - having the first pregnancy after age 30, not breast-feeding, and never having a full-term pregnancy, and drinking alcohol
Which risk factors of breast cancer can PTs have an impact on?
not being physically active, overweight/obesity, and drinking
What is Ductal or Lobular Carcinoma and what is it more specifically called?
Tumors that start in the epithelial cells that line the organs and tissue; adenocarcinomas
Invasive ductal carcinoma makes up about _________% of all breast cancers
70-80
What does In Situ mean?
situated in the original place
Inflammatory breast cancer makes up what percent?
1-5%
What is inflammatory Breast Cancer?
cancer cells that block lymph vessels in the skin
ER/PR + or - Breast cancer denotes __________________
presence or absence of that hormone (estrogen or progesterone)
Triple negative breast cancer
Very aggressive; cancer cells do not have estrogen, progesterone, or the protein HER2
Triple Negative Breast Cancer accounts for _______% of all breast cancers
15
BRCA gene
tumor suppressor genes
Mutations in the BRCA gene cause what?
abnormal growth of cells leading to cancer
____/100 women with a BRCA gene mutation will get Breast cancer by 70 compared to ____/100 women in the general US population
50; 7
Pathologic stage or surgical stage of breast cancer is determined by ________________
examining tissue removed
Clinical stage of breast cancer is based on ________________
results of the physical exam, biopsy, and imaging
Both classifications of staging of breast cancer use what 7 pieces of information
Size of the tumor, spread to nearby lymph nodes, metastasis to nearby sites, estrogen receptor status, progesterone receptor status, HER 2 status, and grade of the cancer
When staging cancer, a T followed by a number 0-4 indicates what?
the primary tumor size and if it has spread to the skin or the the chest wall under the breast
Staging Breast Cancer - T0
no evidence of primary tumor
Staging Breast Cancer - T1
2cm or less across
Staging Breast Cancer - T2
> 2cm but <5cm across
Staging Breast Cancer - T3
> 5cm across
Staging Breast Cancer - T4
Tumors of any size growing into the chest wall or ski. Includes Inflammatory Breast Cancer
When staging cancer, an N followed by a number 0-3 indicates what?
whether the cancer has spread to the Lymph nodes (LN) and if so, how many nodes are involved
Staging Breast Cancer - N0
no lymph node involvement
Staging Breast Cancer - N1
1-3 axillary LN and/or cancer found in internal mammary LN on SLNB
Staging Breast Cancer - N2
4-9 LN
Staging Breast Cancer - N3
10 or more LN or cancer has spread to LN under the clavicle
When staging cancer, an M followed by a 0 or 1 indicates what?
spread to distant organs
Sentinel lymph node biopsy
surgeon injects a dye under the arm and then removes the lymph nodes that have taken up the dye closest to the area of the tumor
Axillary Lymph node Biopsy
Surgeon removes many noes (usually less than 20) from under the arm, which increases the risk of lymphedema
Implications for therapy for Axillary lymph node dissection
Situated near the brachial plexus which innervates the muscles of the upper limb, branches of the plexus originate at the level of the pectoralis minor muscle; long thoracic nerve which originates from C5-C7 nerve root is located in the axilla (both are vulnerable during axillary lymph node dissection)
Axillary lymph node dissection risk factors include ___________ (_____%), _________ (____%), ____________ (_______%), and __________ (_____%)
numbness 39, pain 39, limitation of arm movement 16, and lymphedema 25
What are some different treatment options for breast cancer?
Surgery, Chemotherapy, radiation, and immunotherapy
Which breast cancer treatments increase the risk for lymphedema?
surgery and radiation
What are some types of breast cancer surgeries?
breast conserving, mastectomy, and reconstruction
What are the different types of breast cancer radiation?
External beam radiation and brachytherapy (internal)
Which type of breast cancer radiation is most common
External beam radiation
External beam radiation
standard schedule for getting whole breast radiation is 5 days/week for 6-7 weeks, can include boost
Breast conserving surgery
surgery to remove the cancer as well as some of the surrounding normal tissue (margins)
What else is a breast conserving surgery called?
lumpectomy or partial mastectomy
With a breast conserving surgery, pt will most likely need ________________
radiation therapy
Simple total mastectomy
removes all breast tissue including the nipple, areola, and some overlying skin. Muscle beneath the breast is not removed
Skin-sparing Mastectomy
removes all breast tissue but leaves as much healthy breast skin as possible. This procedure is done when the plan is for immediate reconstruction of the breast, nipple, and areola. This is not a safe option if there is a possibility of tumor cells close to the skin.
Nipple-sparing mastectomy
removes all breast tissue but leaves the nipple, areola, and overlying skin. This option allows for a more “natural” look. This is not recommended if the cancer includes the nipple or Paget’s disease or if cancer is detected in the margins
Modified Radical Mastectomy
removes all breast tissue including the nipple, areola, and axillary lymph nodes. Chest wall muscle is left intact.
Potential side effects of surgery
Restrictions in upper quadrant range of motion, scapular instability, loss of or diminished sensation, scar adhesions, weakness, axillary web syndrome, and lymphedema
according to the NIH _______% develop axillary Web syndrome after ALND and surgery
86
Autologous tissue reconstruction types
Pedicle flap and free flap
Pedicle flap
moves tissue, fat, skin and some of the muscle, from its site to the breast/chest wall while it is still attached to its blood supply. Most common is Latissimus dorsi flap (LD) and transverse rectus abdominus flap (TRAM). *TRAM flap can also be a free flap; Pedicle flaps that do not take any muscle include the thoracodorsal artery perforator (skin and fat from the upper back) and the lumbar artery perforator (skin and fat from lower back)
Free flap
moves tissue, fat, skin, and some of the muscle, but not the blood supply. Free flaps that do not take any muscle include gluteal artery perforator, lateral thigh perforator, and the deep inferior epigastric perforator.
Breast implants
Silicone or saline; Silicone or Saline
Require two surgeries. First surgery is for placement of tissue expanders that will gradually be filled until the desired size is reached. Second surgery replaces the expanders with the implants. Additional surgeries may be needed to reconstruct the nipple, or for revisions to improve the overall look
What are the pros of autologous breast reconstruction
Uses tissue from your own body, tissue will change as your body changes, does not need to be replaced, better able to mimic the look and feel of a natural breast
What are the cons of autologous breast reconstruction
Longer surgery and recovery time, multiple surgical sites, potential donor site problems including muscle damage, abdominal bulging, and muscle weakness, loss of sensation, and risk of tissue necrosis
What are the pros of implant breast reconstruction
shorter surgery and recovery time and fewer scars
Cons of implant breast reconstruction
less able to mimic the look and feel of a natural breast, need to be replaced, requires two separate surgeries, and loss of sensation
Delayed risks from reconstruction surgery include _________________
loss or change in sensation, muscle weakness, scar adhesions, uneven breasts, and fatigue
4-6 weeks post-op pts will be restricted in _____________________ and it may be longer if there is delayed wound healing
overhead lifting, sports activities, and some sexual activities
If tissue expanders are placed, pts will be restricted in ______________, and you need to limit manual therapy techniques over top of tissue expanders
lifting anything over 5-10 pounds for 6 weeks
according to the American Cancer society, most women can resume normal activities within ____________ weeks following surgical procedures
6-8
If you had a mastectomy and no lymph nodes had cancer, the external beam radiation will be focused on _______________________ after surgery
The chest wall, the mastectomy scar, and the places where the drains exited the body
If you had breast-conserving surgery, external beam radiation will be to the _________________, with a boost to _______________________
whole breast; the area in the breast where the cancer was removed
External Beam Radiation is usually not started until ___________________
after surgical sites have healed and after any chemotherapy treatments
External Beam Radiation dosage is measured in ______________
Grays
What is the difference between adjuvant and neoadjuvant?
adjuvant - after surgery; neoadjuvant - getting radiation or chemo before surgery (to try to shrink the tumor)
How long is typical radiation treatment?
5 days a week for 5-6 weeks
Potential risks following radiation
swelling of the breast, skin changes, fatigue, radiation fibrosis, damage to the brachial plexus nerves, weakening of the ribs, and lymphedema
Radiation fibrosis
irreversible condition where there is an excess formation of fibrous connective tissue which causes structural and functional changes
Lymphedema
Long term, chronic condition in which there is an abnormal accumulation of water and proteins in the interstitium and subcutaneous tissues that leads to inflammation and reactive fibrosis of the affected tissues
The cortex of the lymph nodes contains ________________
B cells and lymphocytes
The paracortex of the lymph nodes contains __________________
T cells and dendritic cells
the medulla of the lymph nodes contains _________________
macrophages, plasma cells, and B cells
Lymph vessels send lymph fluid through the nodes. The nodes filter the fluid for ________________. When cancer cells break away from a tumor, the cells can travel through the bloodstream or the lymphatic system and may then end up in the lymph nodes
foreign substances, such as cancer cells and infections
If the lymph nodes are removed, it can leave the affected area without ________________, causing the fluid to back up
a way to drain off the lymph fluid
Where are the anterior (pectoral) axillary lymph nodes located?
Inferior border of pec minor near the lateral thoracic vessels
the anterior (pectoral) axillary lymph nodes receive lymph from _________________
Breast, skin, and muscles of the supraumbilical anterolateral body
the anterior (pectoral) axillary lymph nodes drain lymph to ____________
Central and apical nodes
Where are the posterior (subscapular) axillary lymph nodes located?
Posterior wall of the axilla along the inferior border of the subscapularis
the posterior (subscapular) axillary lymph nodes receive lymph from where
Scapular region and posterior thoracic wall
the posterior (subscapular) axillary lymph nodes drain lymph to where
central and apical nodes
Where are the lateral (humeral) axillary lymph nodes located?
Over the lateral wall of the axilla
the lateral (humeral) axillary lymph nodes receive lymph from where
the arm
the lateral (humeral) axillary lymph nodes drain lymph to where
central, apical, and deep cervical nodes
Where are the central (base of the axilla) axillary lymph nodes located?
the base of the axilla
the central (base of the axilla) axillary lymph nodes receive lymph from where
the anterior, posterior, and lateral axillary lymph nodes
the central (base of the axilla) axillary lymph nodes drain lymph to where?
Apical nodes
The apical (terminal) axillary lymph nodes are located where?
deep in the apex of the axilla
The apical (terminal) axillary lymph nodes receive lymph from where
the anterior, posterior, lateral, and central axillary lymph nodes and the upper breast
The apical (terminal) axillary lymph nodes drain lymph to where
outgoing vessels form the apical nodes form the subclavian lymphatic trunk, drains into the thoracic and lymphatic ducts
Pre-lymphatic channel
vertical structure, how fluid travels from blood capillaries to lymph capillaries
Where are lymph capillaries located?
directly under the epidermis
Lymph capillaries are flat overlapping ____________ cells
endothelial cells
Lymph capillaries ______________ valves
DO NOT contain
What do the anchoring filaments of the lymph capillaries do?
Keep one end of capillary open; allows fluid in: absorbs proteins
The Glycocalyx-layer on the inside of the lymph capillary does what?
New research on how fluid is absorbed; revised starling principle of Fluid exchange
Pre-collectors of the lymph vessels
Channels fluid to larger vessels, absorb some fluid (like capillaries), contain smooth muscle, perforating pre-collector connects superficial and deep lymphatics through the fascia
Lymph collectors
one-way valves that contain lymphangions
Lymphangion
smallest functional unit of lymph collector; contains smooth muscle tissue; innervated by autonomic nervous system; has intrinsic contractions of 6-10/minute, and increases up to 10Xs during exercise
Lymph collectors have no _____________, ________________ only
absorption, transport
