Breast CA & Lymphedema

Question 1

Cancer Warning Signs

Answer 1

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

Question 2

Signs of Breast CA

Answer 2

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

Question 3

Sentinal Lymph Node Biopsy

Answer 3

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.

Question 4

Axillary lymph node dissection (ALND) Procedure

Answer 4

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.

Question 5

ALND Risks

Answer 5

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

Question 6

Lumpectomy

Answer 6

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.

Question 7

Mastectomy Indications

Answer 7

Radical procedure, performed if large or multifocal tumor, local recurrence after tx;

Question 8

Mastectomy Complications

Answer 8

Lymphedema, reoccurrance, infection, skin-flap necrosis, “dog-ears,” Seroma, Hematoma, Fibrosis

Question 9

Modified radical mastectomy

Answer 9

breast tissue + pec fascia + ALND

Question 10

Skin-sparing mastectomy and nipple-sparing mastecotmy

Answer 10

presearve breast skin and outline of the inframammary fold; allows for immediate reconstruction;

Candidates: prophylactic mastectomy, early stage breast CA

Question 11

Extended radical (Halstead) mastectomy

Answer 11

only proposed for a tumor that involved pec major; breast tissue, pec major and ANLD and internal mammary lymph node dissection

Question 12

Contralateral Prophylactic Mastectomy

Answer 12

contraversial; risk is only 3-7%; should not be done if pt has locally advanced breast CA

Question 13

Types of Implants

Answer 13

Inflatable with silicone envelope and valve for saline filling; gell-filled with set volume & shape; expanders

Question 14

Complications of Implants

Answer 14

Capsular contracture, implant loss, glandular defects, scar retractions, nipple areola complex (NAC) dislocation

Question 15

Capsular Contracture

Answer 15

(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

Question 16

Latissimus Dorsi Flap (LDF)

Answer 16

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

Question 17

Transverse Rectus Abdominus Flap (TRAM)

Answer 17

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

Question 18

“Free Flaps” aka Microsurgical techniques

Answer 18

transfers tissue from abdominal, inner thigh or gluteal areas to create breast

Question 19

Free TRAM technique

Answer 19

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

Question 20

DIEP flap; aka perforator flap

Answer 20

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

Question 21

SIEA: Superior Inferior Epigastric Artery flap

Answer 21

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

Question 22

Gluteal Artery perforator flap

Answer 22

skin and fat harvested within pantyline; indicated for thin women with inadequate abdominal adipose; no loss of tissue, no functional loss, concealed scar

Question 23

gracilis flap

Answer 23

gracilis harvested to create B-cup if not enough adipose on abdomen or back; Commonly harvested with reported minimal consequence

Question 24

Microsurgical Breast Reconstruction Recovery

Answer 24

6-8 hrs of surgery with anesthesia
3 weeks no driving
8 weeks no lifting> 5 lbs

Question 25

PT after expanders & final implant

Answer 25

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

Question 26

PT after Flap Procedures (LDF, TRAM, Microsurgery)

Answer 26

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.

Question 27

Cellulitis (signs, sxs, tx)

Answer 27

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

Question 28

Flap Necrosis

Answer 28

death of surgically excised mm, fat, skin 2/2 poor blood supply; will require office debridement or surgical excision

Question 29

Dehiscence

Answer 29

split in incision line which results in open surgical wound

Question 30

Seroma

Answer 30

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

Question 31

Pneumothorax

Answer 31

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

Question 32

Brachial Plexopathy

Answer 32

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

Question 33

Axillary web syndrome

Answer 33

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

Question 34

Risk factors for Lymphedema

Answer 34

Axillary dissection, Mastectomy, Radiation of breast/chest wall & nodes

Maybe higher BMI, AA, increased age, lower UE function, sedentary behavior

Question 35

Precautions for exercise while patient is undergoing Chemo or radiation

Answer 35

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

Question 36

Types of Lymphedema

Answer 36

Acute: less than 5 mo: 60%
Chronic/Progressive: 30-40%
Fluctuating: 15-22%

** Mild are 3x more likely to have mod-sev

Question 37

Objective Measures of Lymphedema

Answer 37

Bioimpedance spectroscopy: observes presence of extracellular fluid
water displacement
perometry
circumferential measures
circumferential measures converted to volume measures

Question 38

Surgical tx of Lymphedema

Answer 38

Debaulking procedures, microsurgery, lymphatic-venous anastomosis;

• Consider when conservative tx has failed, chronic & pitting; need for compression garments will continue after tx.

Question 39

Medications for lymphedema

Answer 39

Benzopyrones
Selenium compounds
pentoxifylline (imprved blood flow in vessels)
Vit E (skin care)