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Breast Cancer Overview – Lymph

BREAST CANCER INFORMATION SHEET

Overview – Understanding Breast Anatomy

At the Massage Clinic Health Centres, we try to support the patient in every stage especially their recovery. When dealing with breast cancer and surgery it is important to address certain issues, such as lymphedema, before continuing on with bra fitting, breast forms and compression garments. Manual Lymphatic Drainage and sometimes bandaging is important to do prior to further fittings. Visit to Manual Lymph Drainage (MLD)

External anatomy of the breast tissue and the surrounding area consists of the following:

  • Areola – a circular pigmented tissue surrounding the nipple
  • Axilla – area under the arm, or the underarm. Tissue may be missing in this area in mastectomy patients
  • Clavicle – collarbone
  • Nipple
  • Sternum – breastbone

Along with the external anatomy, it is also important to note the internal anatomy of the breast tissue, which consist of the following:

  • Lymph nodes – small bean shaped organs that filter lymphatic fluid from the lymph system
  • Lymphatic fluid – protein rich fluid that flows through the body carrying certain cells and waste to be filtered through the lymph nodes
  • Nerves – cordlike structures that transmit stimuli to the brain
  • Deltoid muscle – muscle on the shoulder area that moves the shoulder in every direction
  • Pectoralis muscles – muscle tissue attached to the front of the chest wall and extending to upper arm. This tissue is often removed during standard radical mastectomy and preserved in a modified radical mastectomy.

Signs and Symptoms

Possible breast cancer warning signs include:

  • Mass or thickening in the breast or axilla
  • Skin dimpling, puckering, or nipple retraction
  • Nipple discharge or scaliness
  • Redness
  • Change in size, contour or shape of breast

When a symptom is identified, a mammogram may be advised. A mammogram is used to evaluate both breasts, including the lump and other areas in the same breast. If something is suspicious, it is important to determine whether the lump is benign or malignant. This is usually followed by a biopsy, which is the surgical removal of a lump or portion of a lump or a needle biopsy. In most cases, a biopsy determines diagnosis, and the cancer treatment is performed at a later time. This is called a two-step procedure. The delay between diagnosis and treatment usually does not harm chances for cure and gives the patient time to evaluate various treatment methods.

Types of Breast Cancer

IDC (invasive/infiltrating ductal carcinoma)

-Most common type of breast cancer. Starts in milk duct and breaks through the wall of the duct and invades the breast tissue. From there it can metastasize to other parts of the body

DCIS (ductal carcinoma in situ)

-Most common type of non-invasive breast cancer. The cancer is only in the ducts and has not spread through the walls of the ducts

LCIS (lobular carcinoma in situ)

-This type begins in the milk glands, but does not go through the wall of the lobules. Although this condition is not a “true” cancer, having LCIS increases the risk of getting cancer later. Regular mammograms and check ups are important in this condition

ILC (invasive/infiltrating lobular carcinoma)

-A cancer that starts in the milk glands and can spread to other parts of the body

IBC (inflammatory breast cancer)

-This is an uncommon type of invasive cancer and accounts for 1-3% of all breast cancers. IBC makes the skin of the breast look red and feel warm. It gives the skin a thick, pitted appearance like an orange peel. The breast becomes larger or firmer, tender and itchy.

Breast Cancer Staging

The TNM system is the most common. It stands for Tumour, Nodes, Metastasis. Tumour size determines which category the tumour will fall into. T-1 (tumour size under 2 cm to T-4 (tumour ulcerating through the skin or stuck to underlying chest wall).The most common route of breast cancer metastasis, is to the axillary nodes. The more axillary nodes that are involved, the greater the risk of micrometastasis. The node scale runs from N-0 (no palpable nodes), N-1a (no cancer cells), N-1b (nodes are positive), N-2 (nodes are large and matted together), N-3 (palpable nodes near the collarbone). Metastasis staging runs from M-0 (no metastases) to M-1 (metastases present). MX means metastases cannot be assessed.

Another test for staging breast cancer is a sentinel node biopsy. This surgical procedure involves removing lymph tissue and examining it for signs of cancer.

Stage 0 – in situ cancer, non-invasive intraductal disease of the nipple without detectable tumour; no positive nodes; no metastases

Stage 1 – tumour under 2 cm; no lymph nodes

Stage 2 – small tumour with positive lymph nodes; tumour from 2-5 cm with positive or negative lymph nodes; tumour larger than 5 cm with negative lymph nodes

Stage 3 – large tumour with positive lymph nodes

Stage 4 – tumour with obvious metastases

After staging is complete and the tumour type determined, the oncologist will determine which treatment modality will be most effective.

Breast Surgery Types

Lumpectomy – local excision, quadrantectomy, breast conserving surgery, partial mastectomy or segmental mastectomy. This procedure involves surgical removal of the breast lump where the cancer is located and a portion of the normal surrounding tissue for safety. Removal of some of the axillary lymph nodes occurs at the same time in order to test for possible metastases. This procedure is usually followed by radiotherapy.

Simple mastectomy/total mastectomy – removes the entire breast but without the lymph nodes

Modified radical mastectomy – it is a total mastectomy with axillary dissection and the lining over the chest muscles. Usually the chest muscles are left intact, but sometimes the pectoralis minor is removed.

Radical (halsted) mastectomy – removing significant amounts of chest muscle along with the breast and lymph nodes.

Breast Cancer Treatments

Some common treatments for breast cancer include:

  • Radiation therapy – uses x-rays to kill cancer cells in a localized area. Radiation therapy can also be used prior to surgery in order to minimize the tumour size. It is usually given over a 5-7 week period. It is usually painless with the most common side effects being fatigue and skin changes. Other side effects include breast soreness, swelling and reddening of the skin, dryness, itching, burning. Long term side effects include darkening of the breast tissue, increased or decreased skin sensitivity, thickening of the breast tissue and a change in the size of the breast
  • Chemotherapy – pharmaceutical agent given to kill cancer cells. It is usually a combination of drugs that work together to interfere with the rapid multiplication of cancer cells. This treatment is usually given intravenously and helps to prevent the spread of cancer cells. Unfortunately, these drugs act on all cells that are rapidly dividing including hair, skin, digestive tract and bone marrow cells. The chemotherapy is given in cycles with rest periods to allow the bone marrow time to produce red and white blood cells between treatments.

Understanding Reconstruction

In a breast reconstruction, a new breast is created using either an implant or tissue transfer

  • Implant reconstruction – the process usually starts with a tissue expander into which saline is gradually introduced so that the skin of the chest can be gently stretched until the desired breast shape is achieved. Following the tissue expander, a silicone implant will be inserted to replace the expander implant.
  • Tissue transfer reconstruction – a new breast shape is created using the woman’s own fat, muscle and blood vessels which are transferred from another part of the body.

However, sometimes there can be complications with implants, where the body can reject the implants and the patient can be left with a chest area that is not entirely flat or other complications. It is important for the woman to do their own research and be their own advocate when considering implants because most physicians will automatically suggest implants without considering other options.

Post – Surgery Issues

  • Uneven breast size
  • Concave or uneven scarring
  • Dog-ear – pocket of fatty tissue usually around the axilla
  • Shoulder stiffness and axillary cording – following surgery and treatment axillary cording can develop where the patient has difficulty lifting arm or going through proper range of motion. This can be treated with manual lymphatic drainage and myofascial release through your lymphedema therapist.
  • Numbness in the chest wall, shoulder, or arm following a mastectomy
  • Scar tissue
  • Phantom pain in the area of the removed breast

Lymphedema

  • Lymphedema is a build up of protein rich fluid that causes swelling/edema in the body and is most likely to affect the arm on the operated side following breast surgery especially if lymph nodes were removed. It is important to note that some women will stay in the “latency phase” of lymphedema a long time before developing any lymphedema on the affected side. Lymphedema can develop over time and cause swelling in most cases. It is not curable but it is manageable. If there is fatigue, heaviness, aching, swelling on the affected side further treatment by a lymphedema therapist is advised. This includes manual lymphatic drainage, bandaging, and compression garments. Visit to Manual Lymph Drainage (MLD)