Lymphedema after breast cancer surgery have we made any progress
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Lymphedema after breast cancer surgery: Have we made any progress?. Tina Yen, M.D., MS Department of Surgery Medical College of Wisconsin Milwaukee, WI October 25, 2008. Outline. Symptoms and sequelae Measurements Incidence Risk factors Prevention Treatment. Lymphedema.

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Lymphedema after breast cancer surgery have we made any progress

Lymphedema after breast cancer surgery: Have we made any progress?

Tina Yen, M.D., MS

Department of Surgery

Medical College of Wisconsin

Milwaukee, WI

October 25, 2008


Outline
Outline progress?

  • Symptoms and sequelae

  • Measurements

  • Incidence

  • Risk factors

  • Prevention

  • Treatment


Lymphedema
Lymphedema progress?

  • Accumulation of protein-rich fluid in the surrounding tissues

  • Etiology

    • Surgery

    • Radiation

    • Infection

    • Trauma

  • Lymph transport is interrupted

    • Physical disruption of channels due to surgery

    • Compression of lymphatic channels from radiation or surgical changes

    • Obstruction of lymphatics by tumor

  • Lifetime risk


Lymphedema1
Lymphedema progress?

  • Tissue swelling/edema

  • Repeated episodes of infection

  • Chronic inflammation

    • Stasis of protein-rich fluid

    • Impaired immune clearance

  • Fibrosis (hardening)

  • Variable time of onset

  • Temporary or permanent

  • Variable severity

  • Not curable


Symptoms

Tightness progress?

Fullness

Heaviness

Pain

Other sensory changes

Weakness

Decreased range of motion

Symptoms


Sequelae of lymphedema
Sequelae of lymphedema progress?

  • Physical discomfort and upper extremity disability

    • Alter activities of daily living

  • Cosmetic deformity

  • Recurrent arm infections

  • Psychosocial morbidity

    • Anxiety, depression, and emotional distress

    • Psychological distress

    • Sexual, physical, and social dysfunction

  • Diminished quality of life


Objective measures
Objective measures progress?

  • Circumferential arm measurements

    • Measurements of both arms at various points

  • Volumetric measurements

    • Limb submersion in water

    • More accurate but difficult to perform

  • Skin/soft tissue tonometry

    • Soft-tissue compression is quantified

    • Not standardized procedure


Measurement issues
Measurement issues progress?

  • All three methods employed

  • No standard definition of lymphedema

    • Most common definition is > 2 cm difference between circumference measurements from both arms

  • No reliable or standard measure exists

    • Measure lymphedema

    • Assess the functional impact of lymphedema


Wide variation in lymphedema incidence rates
Wide variation in lymphedema incidence rates progress?

  • Two recent comprehensive reviews (1985-1999)

    • 6% to 30%

    • 0% to 56% (mean 26%)

  • Reasons for variability

    • Retrospective, single-institutional, small numbers

    • Extent of breast and axillary surgery

    • Use and extent of radiation therapy

    • Completeness and duration of follow-up

    • No standardized methods used to define lymphedema

    • No standard time interval to assess for lymphedema

    • Selection bias


Established risk factors for lymphedema
Established risk factors for lymphedema progress?

  • Axillary radiation therapy plus ALND

    • 41% incidence of lymphedema (21% - 51%)

  • Extent of axillary surgery

    • 17% incidence of lymphedema (6% - 39%)

    • Risk of lymphedema increases with the number of lymph nodes removed

  • Issues

    • Older data

    • More extensive operations

    • More frequent use of axillary radiation


Positive progress? for metastases (33%)

ALND

Negative for metastases (66%)

No ALND

Observation

Sentinel lymph node biopsy in breast cancer

Sentinel lymph node biopsy

Selective approach to ALND


Preoperative lymphoscintigraphy progress?

Intraoperative injection of lymphazurin

Axillary SLN

Injection of radiocolloid

Lymphatic Mapping Technique



Lymphedema and arm morbidity after slnb
Lymphedema and arm morbidity after SLNB progress?

  • Compared with ALND patients, SLNB patients have:

    • Less lymphedema (0-7%)

    • Less pain

    • Less numbness

    • Better arm mobility

    • Less psychological morbidity

    • Better quality of life

  • Limitations of current studies

    • Small numbers

    • Single institution

    • Retrospective

    • Short follow-up (12-24 months)


Other potential risk factors
Other potential risk factors progress?

  • Patient age

  • Patient weight/BMI

  • History of arm infections

  • Extent of disease

    • Tumor size

    • Nodal involvement

  • Type of breast surgery (lumpectomy vs. mastectomy)

  • Type of axillary surgery (SLNB vs. ALND)

  • Treatment modalities

    • Radiation therapy

    • Chemotherapy

    • Hormonal therapy

  • Surgeon technique


Population based study of older breast cancer patients
Population-based study of older breast cancer patients progress?

  • Population-based cohort of 2,154 women

    • Aged 65-89 years at time of breast cancer surgery in 2003

  • Reside in California, Florida or Illinois

  • Three telephone surveys

    • Completed at median of 48 months after surgery

    • Variables: demographic and adjuvant treatment

  • Medicare claims

    • Type of breast and axillary surgery

    • Surgeon volume

  • State tumor registries


Self reported lymphedema
Self-reported lymphedema progress?

  • Since your breast cancer surgery, has a doctor ever told you that you have lymphedema or arm edema?

  • Since your breast cancer surgery, have you had hand or arm swelling on the side of your breast cancer surgery that you have not had on the other side?


Results
Results progress?

  • 2,154 women were operated on by 966 different surgeons

  • Majority had early stage disease

    • 17% DCIS

    • 64% Node-negative

    • 18% Node-positive

    • 0.7% Distant disease

  • 64% breast-conserving surgery

  • Type of axillary surgery

    • 19% none

    • 23% SLNB alone

    • 58% ALND

  • 15.5% (n = 333) had self-reported lymphedema at a median of 48 months postoperatively


Univariate analysis
Univariate analysis progress?

  • Younger age (72.1 vs. 72.9 years)

  • Higher BMI

    • Time of surgery (27.7 vs. 26.8)

    • At 48 months postoperatively (27.9 vs. 26.5)

  • More extensive disease

    • Larger tumor size

    • Presence of lymph node metastases

    • Higher tumor stage

  • More extensive surgery

    • Mastectomy vs. lumpectomy

    • ALND vs. SLNB

    • More lymph nodes removed

  • Chemotherapy

  • No association: change in BMI since surgery, race, tumor grade, receipt of radiation or hormonal therapy, and surgeon volume



Number of lymph nodes removed is the only independent predictor of the development of lymphedema

Model also adjusts for patient age, BMI at time of surgery, tumor size, lymph node status, type of breast and axillary surgery, receipt of radiation therapy, chemotherapy, hormonal therapy, and surgeon volume


Study summary
Study summary predictor of the development of lymphedema

  • 15.5% self-reported lymphedema at 4 years

  • Only independent predictor of lymphedema was the removal of > 5 lymph nodes

    • Regardless of whether SLNB or ALND performed

  • Risk of lymphedema

    • No axillary surgery 6.0%

    • SLNB alone 7.4%

  • No association with lymphedema

    • Radiation therapy

    • Surgeon volume

    • Age, BMI, lymph node status, extent of breast surgery, and receipt of chemotherapy or hormonal therapy


  • Study limitations conclusions
    Study limitations/conclusions predictor of the development of lymphedema

    • Limitations

      • Cohort of older women

      • Medicare claims

      • Self-report of lymphedema

    • Conclusions

      • Consider the removal 5 or fewer lymph nodes with SLNB

      • Counsel women undergoing SLNB on their risk of lymphedema


    Prevention of lymphedema
    Prevention of lymphedema predictor of the development of lymphedema

    Principles

    • Production of lymph flow should not be increased

    • Blockage to lymph transport should not be increased

  • Avoid any procedures on the affected arm

  • Avoid punctures or injuries to the skin

  • Keep meticulous skin and nail care

  • Avoid constricting sleeves or jewelry

  • Avoid heat

  • Avoid excessive exercise to the affected arm


  • Lymphedema treatment
    Lymphedema treatment predictor of the development of lymphedema

    • Begin once lymphedema is recognized

    • Options

      • Elevation

      • Compression garments

      • Centripetal massage and exercises

      • Pneumatic compression devices

      • Program of complete decongestive physiotherapy (CDP)/decongestive lymphatic therapy (DLT)


    Complete decongestive physiotherapy
    Complete decongestive physiotherapy predictor of the development of lymphedema

    • Phase I: Treatment phase (1-4 weeks)

      • 1 or 2 75- to 90-minute treatments daily

      • Meticulous skin and nail care

      • Manual lymphatic drainage (MLD)

      • Low-stretch multilayer bandaging

      • Physical therapy in bandages

    • Phase II: Maintenance phase (for life)

      • Meticulous skin and nail care

      • Elastic compression sleeve during the day

      • Low-stretch multilayer bandages overnight

      • Exercises in bandages


    Efficacy of treatments
    Efficacy of treatments predictor of the development of lymphedema

    • Therapies are often used in combination

      • Most common modalities: elevation, massage, and exercise

    • Therapies show a 15% - 75% reduction in arm volume or circumference

    • Need for large randomized studies

      • Relative efficacy of interventions

      • Optimal timing of interventions

      • Effect of treatment on disease progression


    Summary
    Summary predictor of the development of lymphedema

    • Lymphedema causes physical and psychosocial morbidity.

    • Women with breast cancer have a life-long risk of developing lymphedema.

    • In our population-based cohort of older breast cancer women, 15.5% developed self-reported lymphedema at 4 years.

    • In our study, the only risk factor for the development of lymphedema is the removal of more than 5 lymph nodes.

    • Prevention measures are not evidence-based.

    • Treatment can be successful, especially if instituted early.


    Acknowledgements
    Acknowledgements predictor of the development of lymphedema

    • Patient Care and Outcomes Research (PCOR)

      • Ann B. Nattinger, MD, MPH

      • Rodney Sparapani, MS

      • Purushuttom Laud, PhD

      • Xiaolin Fan, PhD

      • Changbin Guo, BS

    • Alonzo P. Walker, MD

    • Funding support

      • NIH/NCI K07CA125586

      • NIH/NCI R01CA81379


    Resources
    Resources predictor of the development of lymphedema

    • National Lymphedema Network

      • www.lymphnet.org

    • National Cancer Institute

      • http://www.cancer.gov/cancertopics/pdq/supportivecare/lymphedema/Patient

    • American Cancer Society

      • http://www.cancer.org/docroot/MIT/content/MIT_7_2x_Lymphedema_and_Breast_Cancer.asp


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