Transcript Post-mastectomy Syndrome

POST-MASTECTOMY
SYNDROME: EVALUATION
Michael D. Stubblefield, M.D.
National Medical Director for Cancer Rehabilitation
Select Medical Corporation
Medical Director for Cancer Rehabilitation
Kessler Institute for Rehabilitation
American Board of Physical Medicine & Rehabilitation
American Board of Electrodiagnostic Medicine
American Board of Internal Medicine
Post-mastectomy Syndrome
Disclosures
None
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Post-mastectomy Syndrome
Key Components of Evaluation
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History
Physical
Laboratory
Imaging
Electrodiagnostic
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Post-mastectomy Syndrome
Key Components of History
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Diagnosis date
Conditions of diagnosis
Histology
Grade
Biomarker status
Stage
Resection
Reconstruction
Chemotherapy
Radiotherapy
Hormonal therapy
Complications
Recurrence
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Post-mastectomy Syndrome
Breast Cancer Histology
• Noninvasive
– Lobular carcinoma in situ
– Ductal carcinoma in situ
• Invasive
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Ductal
Lobular
Mixed ductal/lobular
Mucinous
Comedo
Inflammatory
Tubular
Medullary
Papillary
Li CI, Uribe DJ, Daling JR. Clinical characteristics of different
histologic types of breast cancer. Br J Cancer 2005;93:1046-52.
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Post-mastectomy Syndrome
Biomarker Status
• Estrogen
• Progesterone
• HER2
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Post-mastectomy Syndrome
Breast Cancer Staging
Tumor
Nodes
Metastases
Stage 0
Tis
N0
M0
Stage IA
T1*
N0
M0
Stage IB
T0
N1mi
M0
T1*
N1mi
M0
T0
N1**
M0
T1*
N1**
M0
T2
N0
M0
T2
N1
M0
T3
N0
M0
Stage IIA
Stage IIB
*T1 includes T1mi
**T0 and T1 tumors with nodal micrometastases only are excluded from Stage IIA and are classified as Stage IB
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Post-mastectomy Syndrome
Breast Cancer Staging
Tumor
Nodes
Metastases
T0
N2
M0
T1*
N2
M0
T2
N2
M0
T3
N1
M0
T4
N0
M0
T4
N1
M0
T4
N2
M0
Stage IIIC
Any T
N3
M0
Stage IV
Any T
Any N
M1
Stage IIIA
Stage IIIB
*T1 includes T1mi
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Post-mastectomy Syndrome
Breast Resection
Types
Tissue Removed
LN Dissection
Reconstruction
Lumpectomy
Breast tissue (minimal)
No
No
Partial mastectomy
Breast tissue (more)
No
No
Subcutaneous “nipplesparing” mastectomy
Breast tissue
No
Yes
Skin-sparing Mastectomy
Breast tissue, nipple
No
Yes
Simple/total Mastectomy
Breast tissue, fascia, nipple, skin
No
Yes
Modified Radical Mastectomy
Breast tissue, fascia, nipple, skin
Yes (Levels I, II)
Yes
Radical Mastectomy
Breast tissue, fascia, nipple, skin,
pectoralis major and minor
Yes (Levels I, II,
III)
Yes
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Post-mastectomy Syndrome
Lumpectomy & Partial Mastectomy
• Lumpectomy involves removal of
the breast tumor (the "lump")
and a small amount of normal
surrounding tissue
• Partial mastectomy involves
removal of the breast tumor and
a larger amount of normal
surrounding tissue relative to
lumpectomy
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Post-mastectomy Syndrome
Mastectomy Incisions
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Post-mastectomy Syndrome
Subcutaneous (“Nipple-Sparing") Mastectomy
• Subcutaneous ("nipple-sparing")
mastectomy involves removal of
all breast tissue with preservation
of the nipple
• Subcutaneous mastectomy is
performed less often than simple
or total mastectomy because
residual breast tissue may harbor
cancer cells
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Post-mastectomy Syndrome
Skin-sparing Mastectomy
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Post-mastectomy Syndrome
Skin-sparing Mastectomy
• In a skin-sparing mastectomy, all
of the breast skin, except the
nipple and the areola, is
preserved. This makes
reconstruction easier and most
importantly avoids making any
scars on the breast, allowing for
better results after breast
reconstruction
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Post-mastectomy Syndrome
Simple/Total Mastectomy
• Appropriate for women with
multiple or large areas of ductal
carcinoma in situ (DCIS) and for
women seeking prophylactic
mastectomies.
• Entire breast removed.
• No axillary lymph node
dissection.
• No muscles are removed.
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Post-mastectomy Syndrome
Modified Radical Mastectomy
• Generally used for invasive breast
cancer.
• Entire breast removed.
• Axillary lymph node dissection
(levels I and II) performed.
• No muscles are removed from
beneath the breast
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Post-mastectomy Syndrome
Radical Mastectomy
• Used when the breast cancer has
spread to the chest muscles
under the breast.
• Rarely performed because
modified radical mastectomy is as
effective with less disfigurement.
• Entire breast removed.
• Levels I, II, and III lymph nodes
removed.
• Pectoralis muscles removed.
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Post-mastectomy Syndrome
Lymph Node Dissection
• Level I is the bottom level,
below the lower edge of the
pectoralis minor muscle.
• Level II is lying underneath
the pectoralis minor
muscle.
• Level III is above the
pectoralis minor muscle.
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Post-mastectomy Syndrome
Sentinel Lymph Node Biopsy
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Post-mastectomy Syndrome
Breast Reconstruction Options
• Implants
– Immediate implant
– Tissue expander
Implant
• Autologous tissue transplantation
– Fat grafting
– Pedicle flap
• Transverse Rectus Abdominis Myocutaneous Flap (TRAM)
– Free/muscle sparing flap
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Transverse Rectus Abdominis Myocutaneous Flap (TRAM)
Deep Inferior Epigastric Perforator (DIEP)
Transverse Upper Gracilis (TUG)
Gluteal Free Flap/Gluteal Artery Perforator (GAP)
• Breast implants and autologous tissue transplantation
– Latissimus dorsi flap
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Post-mastectomy Syndrome
Tissue Expander
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Post-mastectomy Syndrome
Breast Implant
• Implants have a silicone shell
filled with either silicone gel or
saline.
– Silicone gel-filled implants do not
increase the risk of immune
system dysfunction.
– “Gummy bear” implants and are
made of highly cohesive silicone
and are more accurately called
form-stable implants.
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Post-mastectomy Syndrome
“Gummy Bear” Implants
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Post-mastectomy Syndrome
Pedicle TRAM
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Skin, fat, blood vessels, and at least one
abdominal muscle from the lower abdomen
are moved to the chest.
Leaves the flap attached to its original blood
supply (pedicle) and tunnels it under the skin
to the chest.
Implant may not be needed in women with
enough tissue to shape breast
Can decrease abdominal strength.
May not be possible in women who have had
abdominal tissue removed in previous
surgeries.
Increased hernia risk.
Abdominal site is closed as modified
abdominoplasty
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Post-mastectomy Syndrome
Free/Muscle Sparing TRAM
• Required less muscle than pedicle TRAM.
• Free flap requiring microsurgical
anastomose to the thoracodorsal or
internal mammary artery.
• Surgery takes longer than pedicle TRAM
flap.
• The blood supply to the flap is usually
better than with pedicle flap.
• Donor site often more cosmetic
• Less hernia risk than pedicle TRAM
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Post-mastectomy Syndrome
Deep Inferior Epigastric Perforator (DIEP) Flap
• Uses fat and skin from the same
area as the TRAM flap but NOT
muscle to form the breast mound.
• Results in reduced fat in the lower
abdomen (“tummy tuck”).
• Free flap requiring microsurgery to
anastomose blood vessels.
• Less risk of a hernia because no
muscle is taken.
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Post-mastectomy Syndrome
Transverse Upper Gracilis (TUG) Flap
• Uses muscle and fatty tissue from
along the bottom fold of the buttock
extending to the inner thigh.
• Free flap requiring microsurgery to
anastomose blood vessels.
• Not a good option for women with thin
thighs.
• Only available in some centers.
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Post-mastectomy Syndrome
Gluteal Free Flap/Gluteal Artery Perforator (GAP)
• Uses tissue from the buttocks,
including the gluteal muscle, to create
the breast mound.
• Free flap requiring microsurgery to
anastomose blood vessels.
• It may be an option for women who
cannot or do not wish to use the
abdominal sites due to thinness,
incisions, failed flap, or other reasons.
• Only available in some centers.
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Post-mastectomy Syndrome
Latissimus Dorsi Flap
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Tunnels muscle, fat, skin, and blood
vessels from the upper back under
the skin to the front of the chest.
Usually used in combination with a
tissue expander because the
latissimus does not provide
adequate tissue to create a breast
mound.
Can sometimes be used without an
implant.
Creates new chest scars and a donor
site scar.
Can cause weakness in the back,
shoulder, or arm.
A robust flap that can be used in
women who smoke or have other
issues that delay healing.
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Post-mastectomy Syndrome
Neoadjuvant/Adjuvant Chemotherapy for Breast Cancer
• HER2-negative disease
– Dose-dense AC (doxorubicin/cyclophosphamide) followed by paclitaxel every
2 weeks
– Dose-dense AC (doxorubicin/cyclophosphamide) followed by weekly
paclitaxel
– TC (docetaxel and cyclophosphamide)
• HER2-positive disease
– AC followed by T + trastuzumab ± pertuzumab
(doxorubicin/cyclophosphamide followed by paclitaxel plus trastuzumab ±
pertuzumab)
– TCH (docetaxel/carboplatin/trastuzumab ± pertuzumab
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Post-mastectomy Syndrome
Radiotherapy in Breast Cancer
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Whole Breast Radiation
– Targets majority of breast tissue
– May use wedges, IMRT, respiratory
gating, prone positioning, etc. to
obtain uniform dose distribution with
minimal normal tissue toxicity
– Dose usually 45-50 Gy in 23-25
fractions or 40-42.5 Gy in 15-16
fractions
– Boost to tumor bed recommended
for higher risk patients (age <50 years
and high-grade disease)
– Typical boost doses 10-16 Gy at
2Gy/fx
– Dose schedules are given 5 days per
week
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Post-mastectomy Syndrome
Breast Radiotherapy - Supine
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Post-mastectomy Syndrome
Breast Radiotherapy - Prone
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Post-mastectomy Syndrome
Breast Radiotherapy - Boost
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Post-mastectomy Syndrome
Radiotherapy in Breast Cancer
• Chest Wall Radiation
– Targets includes ipsilateral chest wall, mastectomy scar, and drain sites
where possible
– My include breast reconstruction
– CT-based treatment planning should be used to minimize exposure to
lung and hear.
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Post-mastectomy Syndrome
Radiotherapy in Breast Cancer
• Regional Nodal Radiation
– CT-based treatment planning should be used
– Prescription depth for paraclavicular and axillary nodes varies based
on patient anatomy
– Dose 50-50.4 Gy in 1.8-2.0 Gy fractions
– May include scar boost of 2 Gy per fraction to total dose of 60 Gy
– Dose schedule 5 days per week
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Post-mastectomy Syndrome
Standard 3-field vs. IMRT for Supraclavicular Lymph
Nodes and Chest Wall in Breast Cancer
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Post-mastectomy Syndrome
Upper Body Pain Disorders in Breast Cancer Survivors
Neuromuscular
Cervical radiculopathy
Leptomeningeal disease
Brachial plexopathy
Polyneuropathy
Chemotherapy Induced Peripheral Neuropathy
Diabetic Peripheral Neuropathy
Mononeuropathy
Dorsal scapular (Rhomboids C5)
Suprascapular (Supraspinatus and infraspinatus C5-C6)
Long thoracic (Serratus anterior (C5-C6-C7)
Lateral pectoral (Pectoralis major and minor (C5 to T1)
Medial Pectoral (Pectoralis major and minor (C5 to T1)
Thoracodorsal (Latissimus dorsi C6-C7-C8)
Median
Carpal tunnel syndrome
Ulnar
Cubital tunnel
Guyon canal
Radial
Radial groove
Intercostal
Anterior cutaneous branch
Lateral cutaneous branch
Anterior branch
Intercostobrachial (lateral cutaneous branch of 2nd intercostal nerve)
Complex Regional Pain Syndrome
Musculoskeletal
Post-surgical pain
Rotator cuff disease
Bicipital tendonitis
Adhesive capsulitis
Bony metastases
Epicondylitis
DeQuervain’s tenosynovitis
Arthralgias
Arthritis
Lymphovascular
Lymphedema
Axillary web syndrome/cording
Deep vein thrombosis
Post-thrombotic syndrome
Integumentary
Cellulitis
Radiation dermatitis
Radiation fibrosis
Seroma
Implant rupture
Stubblefield MD, Keole, N. Upper Body Pain and Functional Disorders in Breast
Cancer Patients. PMR. 2014;6(2):170-83.
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Physical Examination
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Post-mastectomy Syndrome
Physical Examination by System/Body Area
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Constitutional
Eyes
ENMT
Neck
Respiratory
Cardiovascular
Breasts
Gastrointestinal (Abdomen)
Genitourinary
Lymphatic
Musculoskeletal
Skin
Neurologic
Psychiatric
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/downloads/eval_mgmt_serv_guide-ICN006764.pdf
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Post-mastectomy Syndrome
Physical Examination by System/Body Area
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Breasts
Gastrointestinal (Abdomen)
Lymphatic
Musculoskeletal
Skin
Neurologic
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/downloads/eval_mgmt_serv_guide-ICN006764.pdf
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Post-mastectomy Syndrome
Physical Examination - Breasts
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Scars
Symmetry
Capsule contraction
Necrosis
Atrophy
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Post-mastectomy Syndrome
Physical Examination - Abdomen
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Scars
Hernias
Muscle contraction
Seroma
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Post-mastectomy Syndrome
Physical Examination - Musculoskeletal
• Inspection: atrophy, deformity, asymmetry, spasm,
fasciculations, myokymia, posture, scapulothoracic motion
• Palpation: muscles(cervical paraspinals, trapezius, rhomboids,
levator scapulae, pectoralis major, serratus anterior), joints,
tendons, ligaments for tenderness, spasm, consistency
• Maneuvers: AROM, PROM, Neer’s, Hawkin’s, empty can test
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Post-mastectomy Syndrome
Physical Examination - Lymphatic
• Lymphedema
• Cording/Axillary Webbing
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Post-mastectomy Syndrome
Physical Examination - Skin
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Radiation changes
Cellulitis
Seroma
Tattoos
Mediport
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Post-mastectomy Syndrome
Physical Examination - Neurologic
• Strength
• Reflexes
• Sensory changes
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Post-mastectomy Syndrome
Laboratory Testing
• Complete blood count with differential
• Comprehensive metabolic profile
• B-12 level (with methylmalonic acid & homocysteine if
equivocal)
• Lyme titer
• TSH
• Vitamin D levels
• ANA/RF
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Post-mastectomy Syndrome
Imaging
• Implant rupture
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MRI
USG
CT
Mammography
• Shoulder (RTC tendonitis, adhesive capsulitis, AVN)
– X-ray
– MRI
– CT
• Spine (Stenosis, disk)
– X-ray
– MRI
– CT
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Post-mastectomy Syndrome
Electrodiagnostic Evaluation
• Denervation changes observed in the pectoralis major muscle
• Chronic denervation in 16/20 patients (80%)
• Pectoral nerve injury during lymph node dissection
Tashiro K, Furukawa M, Nakata T, et al. [Electrophysiological study on
the atrophied pectoralis major muscle after modified radical
mastectomy]. Nihon Geka Gakkai Zasshi. Mar 1989;90(3):429-433.
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Thank You!
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