2. Breast Cancer
Types of breast cancer:
- Ductal carcinoma in situ – cancer at its’ earliest stage – 97% curable
- Lobular carcinoma in situ (pre cancer) -isn’t generally considered
cancer, but will suggest a high probability of getting it. Most likely to occur
in both breasts
- Infiltrating lobular carcinoma
- Infiltrating ductal carcinoma
- Inflammatory breast cancer (rare & most severe) – very fast growing
and prone to metastasis
3. Breast Cancer Staging
TNM
Size of tumor (T)
Has cancer spread to lymph nodes? If so, how many? Has the cancer spread to other nodes in
the neck or chest? (N)
Has the cancer metastasized to other parts of the body? (M)
Possible tests to determine metastasis:
X-rays
Blood tests
CT scan
Pet scan
MRI
4. Estrogen/progesterone receptor positive tumors:
Respond to therapy with anti-estrogen medications
Medications such as Tamoxifen block the estrogen receptors
HER-2/neu:
Gene that when activated helps tumors grow by producing a specific growth-stimulating
receptor.
Tumors that have more than the normal amount of this protein (HER2-positive) may
benefit from the drug Herceptin or Tykerb, which blocks the growth of tumors activated
by the gene
Tumor grade: evaluation of how abnormal the cells appear when
examined under a microscope. A lower grade typically implies a less
aggressive tumor
5. Lymphovascular or perineural invasion: sometimes the tumor cells can invade the
blood vessels, or the lymph or nerve channels within breast tissue.
Gene expression profiling: oncotype DX is a test that is used to analyze the expression
pattern of 21 genes in patients who have tumors that are estrogen - receptor- positive and
axillary-lymph-node-negative.
The pattern is translated into a recurrence “score”
Who will benefit from chemotherapy
Who will be safely spared from chemotherapy
Optimal treatment is determined for each individual
6. Lumpectomy: surgical removal of the tumor and a border of healthy breast tissue.
Potential side effects:
Increased risk of lymphedema if radiation treatment accompanies the procedure
Skin tightness/adhesions
Partial/segmental mastectomy: surgical removal of the cancer, a wedge of normal tissue
around it, and the lining over the chest muscle.
Potential side effects:
Skin tightness / adhesions
Muscular weakness (primarily serratus anterior) causing muscular instability of
the shoulder girdle
if axillary nodes are removed
Increased risk of lymphedema if axillary nodes are removed
7. Total/simple mastectomy: surgical removal of the entire breast and usually a few axillary
lymph-nodes.
Potential side effects:
Skin tightness / adhesions
Painful and difficult movement of the arm and shoulder
Increased risk of lymphedema if axillary nodes are removed
8. Skin-sparing mastectomy: is performed to facilitate immediate breast
reconstruction.
The incisions are smaller than they are for a modified radical or simple mastectomy.
Most of the breast tissue is removed, but most of the breast skin is saved to hold and
shape the reconstructed breast.
Skin-sparing mastectomies have not been shown to increase the risk of recurrence in
patients with early stage breast cancer.
Commonly used for prophylactic mastectomies with immediate reconstruction.
Potential side effects:
Skin tightness / adhesions across chest and in armpit
Muscular weakness (primarily serratus anterior) causing muscular instability of
the shoulder girdle
Painful and difficult movement of the arm and shoulder
Increased risk of lymphedema
Frozen shoulder
9. Subcutaneous mastectomy: is a type of skin-sparing mastectomy that removes tissue
through an incision under the breast, leaving the skin, areola, and nipple intact
Some women who have prophylactic mastectomies prefer them because it retains the nipples and
offers a great cosmetic result
The new breast is reconstructed without any visible scars
Higher risk of recurrence because of the amount of tissue left behind so it’s only considered
appropriate prophylactically.
Potential side effects:
Skin tightness / adhesions across chest
Painful and difficult movement of the arm and shoulder
Increased risk of lymphedema if lymph nodes are removed
Muscular weakness (primarily serratus anterior) causing muscular instability of the
shoulder girdle
10. Modified radical mastectomy: surgical removal of the breast, many of the axillary
lymph-nodes, and some additional fat and skin.
Potential side effects:
Skin tightness / adhesions across chest and in armpit
Muscular weakness (primarily serratus anterior) causing muscular
instability of the shoulder girdle
Painful and difficult movement of the arm and shoulder
Increased risk of lymphedema
Frozen shoulder
11. Nipple-sparing mastectomy – in this procedure the nipple and areola are
left in place while the breast tissue under them is removed.
Women who have a small early stage cancer near the outer part of the breast, with no
signs of cancer in the skin or near the nipple, are better candidates for nipple-sparing
surgery.
Cancers that are larger or nearby may mean that cancer cells are hidden in the nipple.
Some doctors give the nipple tissue a dose of radiation during or after surgery to try
and reduce the risk of the cancer coming back.
There are still some problems with nipple-sparing surgeries. Afterward, the nipple
does not have a good blood supply, so sometimes it can wither away or become
deformed.
Because the nerves are also cut, there is little or no sensation left in the nipple.
In some cases, the nipple may look out of place later, mostly in women with large
breasts. This type of surgery is not yet widely available.
12. Potential side effects of nipple-sparing mastectomy:
Skin tightness / adhesions
Muscular weakness (primarily serratus anterior) causing muscular instability of the
shoulder girdle if an axillary lymph node dissection is performed
Painful and difficult movement of the arm and shoulder
Increased risk of lymphedema with radiation and axillary lymph node dissection
Frozen shoulder
13. Radical mastectomy: removal of the entire breast, chest muscles, all of the axillary
lymph nodes, and some additional fat and skin.
Potential side effects:
Deformity / large depression in the chest wall
Inability to bring arm across the chest in a raised position (horizontal
adduction)
Muscular weakness (primarily serratus anterior) causing muscular instability
of the shoulder girdle
Reduced shoulder stabilization and ability to rotate the shoulder blade upward,
limiting the ability to raise the arm out, away from the body (abduction), or in
front of the body (flexion)
Possible pulmonary problems
Increased risk of lymphedema
Frozen shoulder
14. Axillary lymph-node dissection: excision of some of the lymph-nodes under the arm.
Potential side effects:
Lymphedema
Reduced arm and shoulder function
Weakness in the serratus anterior
Tightness in the skin under the arm
Numbness
Recurrent infections
Frozen shoulder
Axillary web syndrome
15. Axillary web syndrome
Lymphatic cording-a visible web of axillary skin overlying palpable cords of tissue.
6% incidence between 1-6 weeks
May occur in the axilla, elbow joint, wrist, and/or trunk
Physical therapist needs to perform long tissue stretching and myofacial techniques
Patient must do home-based stretching program
Active ROM and passive ROM should improve, pain will decrease, but visible signs of
cording may always be present
Sentinel-node biopsy: removal of a single sentinel node to determine if the cancer has spread
into the lymph-nodes.
Potential side effects:
Minimal tightness in the skin under the arm
Increased risk of lymphedema
16. SLNB = sentinel lymph node biopsy
ALND = axillary lymph node dissection
XRT = radiation therapy
Number of lymph nodes removed correlates with the risk of developing lymphedema.
Risk is approximately ½ with SLNB
SLNB = 8%
SLNB +XRT = 17%
ALND = 15%
ALND + XRT = 30%
Chemotherapy port: - under-the-skin (subcutaneous) port that has been implanted by
a surgeon.
Located either in the arm or chest
Catheter protects the vein during treatment
Can be used for a blood draw, as well as infusion of drugs
17. Range of Motion Limitations Following
Surgery Pilates Personal Trainer
Shoulder Flexion Rib cage arms Pullover w/dowel
Arm circles Forward wall walk
Small arm circles (1 lb. wgts.)
Shoulder Extension Chest expansion Shoulder extension (w/dowel)
Magic Circle at the back
Small arm circles (1 lb. wgts)
Shoulder Abduction Small arm circles (1 lb. wgts) Side wall walk
Saw Self-assisted abduction
Shoulder Internal Rotation Band at side internal rotation
Back scratcher (w/dowel)
Small arm circles (1 lb. wgts)
Shoulder External Rotation Band at side external rotation Back scratcher (w/dowel)
Small arm circles (1 lb. wgts) Traffic cop
Single arm salute
Palms up/down
18. Breast Reconstruction
Saline implants- a “balloon” filled w/ saline and placed beneath the skin either on top of or
beneath the chest muscle.
Tissue Expander- is only partially filled before placement. Over the course of 6 wks. It’s
gradually filled w/ more fluid.
Complications:
Capsular contracture-a painful condition in which scar tissue around the implant hardens
then contracts.
- It may cause deformity, pain, abnormal firmness of the breast.
- Frequent massage and exercise may help, but surgical correction may be
necessary.
The pectoralis major may react by going into painful spasms.
Rupture
Loss or changes in nipple and breast sensation
19. Latissimus Dorsi Flap:
A “tunnel” is created under the skin of the armpit.
The muscle is pulled through and out the mastectomy scar in front.
The muscle is used to form a breast mound, or more commonly, a pocket where an implant is
placed.
The skin is then sewn into place with all of the blood vessels in tact (3-6 hrs).
Potential side effects:
Weakness in the muscles supporting the shoulder blade
Tissue death (necrosis)
Blood clots
Infection
Prolonged healing time
Loss or changes in nipple and breast sensation
20. Postural Deviations and Corrections Following a Lat Flap
Round Shoulder Syndrome
Pilates Personal Trainer
Hug a tree Chest fly (no weight)
Spine stretch forward Door or corner stretch
Chest expansion Active Isolated or PNF stretching
Rowing into sternum High/low row
Rowing at 45˚ Reverse fly
21. Yoga (will have the benefit of strengthening, stabilization, and ROM):
Have your client begin with a breathing exercise-
Corpse Pose (Savasana): this exercise, if done correctly, will stimulate blood circulation
and will lessen or relieve fatigue, nervousness, asthma, constipation, diabetes, indigestion,
and insomnia. It will also improve one’s mental concentration. Breathing should take place
through the nose, from the belly, using full capacity of the lungs. Have your client focus on
their diaphragmatic breathing, letting the exhaling take a little longer than the inhaling.
Have them hold the pose for several minutes, keeping their mind still and focusing on their
breathing and their body.
Upper back strengthening
Spinal balance: have client assume a “neutral spine” in an “all fours” position then
have them extend one leg out (with the option to extend opposite arm in front). If they
can do this with relative ease, have them alternate to the other leg and arm. One move,
one breath: inhale and extend, exhale and close.
22. Locust pose: have client ease into pose as they figure out what their ROM limitations
are. Because they will most likely have an implant under the LAT flap, advise them to
listen to their body and if they feel undue pain or pressure on the chest wall have them
try one of the options below.
Options: feet on or off the floor; hands either under forehead (elbows out); arms along the body;
or arms over head.
Sphinx pose
Chest stretching
Locust pose: have client ease into pose as they figure out what their ROM limitations
are. Because they will most likely have an implant under the LAT flap, advise them to
listen to their body and if they feel undue pain or pressure on the chest wall have them
try one of the options below.
Options: feet on or off the floor; hands either under forehead (elbows out); arms
along the body; or arms over head.
23. Bow pose - have client ease into pose as they figure out what their ROM limitations
are. Because they will most likely have an implant under the LAT flap, advise them to
listen to their body and if they feel undue pain or pressure on the chest wall have
them try the half bow pose.
Option: Half Bow pose
Upward Facing Dog: this should be executed by a client who has close to full ROM
in flexion. Because of the additional force exerted onto the affected limb, have them
elevate that arm following the exercise, and pump their fist open and closed. This will
help to promote lymph drainage. Monitor for signs of swelling.
Table Top (fists for wrists if wrists concerns): this is somewhat of an advance move
for a client lacking a latissimus muscle and having to contend with tightness and
possible scar tissue in the chest wall, however it is very effective. Save this exercise
for your client who is further out from their surgery date and has fully recovered, has
moderate strength, and good flexibility in shoulder extension.
24. Staff pose: they should proceed gingerly and progress in their own comfort zone. They
may struggle initially do to the inherent weakness after the latissimus muscle has been
removed. The smaller shoulder stabilizers will compensate and eventually allow them
to perform this pose with greater ease. Because of the additional force exerted onto the
affected limb, have them elevate that arm following the exercise, and pump their fist
open and closed. This will help to promote lymph drainage. Monitor for signs of
swelling.
* In all the poses, depression and retraction of the scapulae are imperative for shoulder
stabilization.
Shoulder girdle stabilization
Downward Facing Dog: have your client roll their shoulders away from their ears.
Dolphin Plank pose : shoulders over the elbows
Option: knees on the floor
Dolphin pose
* In all poses, depression and retraction of the scapulae are imperative for shoulder
stabilization.
