Page updated 1/31/12
 |
| |
 |
| |
 |
Lymphland International Lymphedema Online
January 3, 2012
J Mal Vasc. 2011 Dec 21. [Epub ahead of print]
[Designing a therapeutic education program for patients with lymphedema: Live with lymphedema.]
[Article in French]
Blaise S, Villemur B, Richaud C, Rastel D, Bucci B, Evra V, Bouchet JY; les membres du réseau
GRANTED, Satger B.
Source
Department of Vascular Medicine, clinique de médecine vasculaire, Grenoble University Hospital, BP 217,
38043 Grenoble cedex 09, France; Réseau GRANTED, 38400 Saint-Martin-d'Hères, France.
Abstract
BACKGROUND:
Lymphedema is a chronic condition considered to be rare in its primary form and potentially frequent in
women after breast surgery for cancer: 27,000new cases annually. Therapeutic management is a serious
challenge. In France, the health authorities (Haute Autorité de santé [HAS]) have recently proposed that
appropriate management practices for lymphedema include "patient education". The HAS and the National
institute for health care prevention and education also published a methodology guide devoted to structuring
a therapeutic education program for patients with chronic disease. Current hospital regulations state that this
education program is part of the care to be delivered to patients with chronic disease and that it must comply
with the national directives. The purpose of our present work was to present the concept and the contents of
a patient education program entitled "Live with lymphedema" designed for patients with lymphedema and
developed within the inpatient-outpatient network GRANTED in Sud-Isère.
METHODS:
A standard detailed educative approach was applied. It was designed after the educational program for
patients with lower limb arterial occlusive disease authorized by the Rhône-Alpes regional health agency. It
was adapted to the specific problematic of patients with lymphedema, including medical management,
rehabilitation, dermatology and nutritional aspects. It was developed in cooperation with patients and favors
local associative actions.
RESULTS:
The specifically structured program included three therapeutic education consultations and five workshops.
Less than one year after its institution, more than 30 patients have participated in the program.
DISCUSSION:
We report a structured patient education program designed for patients with lymphedema. This program
was authorized by the Rhône-Alpes regional health agency in March 2011and is in compliance with the
national directives and HAS guidelines.
Copyright © 2011 Elsevier Masson SAS. All rights reserved.
PMID: 22196687 [PubMed - as supplied by publisher]
January 9, 2012
J Cutan Pathol. 2012 Jan;39(1):52-5. doi: 10.1111/j.1600-0560.2011.01785.x.
Lymphangiosarcoma arising after 33 years within a background of chronic filariasis: a case report with
review of literature.
Krishnamoorthy N, Viswanathan S, Rekhi B, Jambhekar NA.
Source
Department of Pathology, Tata Memorial Hospital, Mumbai, India.
Abstract
Cutaneous angiosarcoma or lymphangiosarcoma represents an uncommon aggressive tumor known to arise
on a background of chronic lymphedema secondary to various etiologies, principally following surgery or
irradiation. There have been rarely reported cases of angiosarcoma following infective conditions that
eventuate with lymphatic stasis. We report a case of angiosarcoma arising after 33 years within a
background of filariasis. Awareness of this association can lead to early diagnosis and appropriate treatment
of this potentially fatal malignant tumor. Krishnamoorthy N, Viswanathan S, Rekhi B, Jambhekar NA.
Lymphangiosarcoma arising after 33 years within a background of chronic filariasis: a case report with
review of literature.
Copyright © 2011 John Wiley & Sons A/S.
PMID: 22211335 [PubMed - in process]
Med Oncol. 2011 Dec;28 Suppl 1:22-30. Epub 2010 Sep 9.
Whether drainage should be used after surgery for breast cancer? A systematic review of randomized
controlled trials.
He XD, Guo ZH, Tian JH, Yang KH, Xie XD.
Source
Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, No. 199
Donggang West Road, Lanzhou, Gansu, 730000, China, hxdls58@163.com.
Abstract
A systematic review of randomized controlled trials (RCTs) was conducted to evaluate whether patients
benefit from the suction drainage after axillary lymph node dissection (ALND) in breast cancer surgery.
RCTs of drainage versus no drainage after ALND in women with breast cancer were retrieved from
PubMed, EMBASE, Cochrane Library and Chinese Biomedical database. Two authors independently
assessed the quality of included trials and extracted data. Odds ratio (OR) for dichotomous outcomes and
mean difference (MD) for continuous outcomes were presented with 95% confidence intervals (CI). A total
of 1115 titles were indentified from the databases; 1109 obvious irrelevant studies were excluded by
examining the titles, abstracts, full texts because of duplicates, no RCT, different modality of drainage, drain
for lymphedema, application of fibrin sealant and so on. And then, only 6 RCTs to compare drainage with
no drainage after ALND in breast cancer surgery were included in the systematic review and a total of 585
patients were included in the pathological diagnosis of breast cancer in women before surgery, management
by ALND with or without addition surgical procedures. The study demonstrated that insertion of a drain in
the axilla after breast cancer surgery resulted in a statistically significant reduction in the rate of seroma (OR
= 0.36, 95% CI, 0.16 to 0.81, P = 0.01), the volume of aspiration (MD = -100.10, 95% CI, -174.36 to
-25.85, P = 0.008), or the frequency of seroma aspiration (MD = -1.03, 95% CI, -1.35 to -0.71, P <
0.00001), but prolonged the length of hospital stay (MD = 1.52, 95% CI, 0.36 to 2.68, P = 0.01). There
was no statistically significant difference in the incidence of wound infection (OR = 0.67, 95% CI, 0.34 to
1.32, P = 0.25) between drainage group and no drainage group. Based on the current evidence, insertion of
a drain in the axilla following ALND in breast cancer surgery effectively decreased seroma formation,
volume of aspiration as well as the frequency of seroma aspiration without increasing the incidence of wound
infection, but extending their stay in hospital.
PMID: 20827578 [PubMed - in process]
J Vasc Surg. 2011 Dec 29. [Epub ahead of print]
Technique, results, and postoperative patency of lymphaticovenous side-to-end anastomosis in peripheral
lymphedema.
Maegawa J, Yabuki Y, Tomoeda H, Hosono M, Yasumura K.
Source
Department of Plastic and Reconstructive Surgery, Yokohama City University Hospital, Yokohama, Japan.
Abstract
OBJECTIVE:
Lymphaticovenous anastomosis has been used for patients with peripheral lymphedema. However, the
efficacy of this procedure is controversial due to a lack of evidence regarding postoperative patency. We
sought to determine midterm postoperative patency of lymphaticovenous side-to-end anastomoses
(LVSEAs) using indocyanine green fluorescence lymphography.
METHODS:
This was a retrospective observational study set in a teaching hospital. Of 107 patients with chronic
lymphedema who underwent 472 LVSEAs, 57 (223 anastomoses) consented to fluorescence
lymphography and comprised the study cohort. The intervention consisted of a microsurgical LVSEA
performed with a suture-stent method. Patients also had preoperative and postoperative complex
decongestive physiotherapy. Anastomosis patency was assessed using indocyanine green fluorescence
lymphography ≥6 months after surgery. Patency rates were calculated using Kaplan-Meier analysis. We
assessed volume reduction on the operated-on limb and compared this between patients in whom
anastomoses were patent and those in whom anastomoses were not obviously patent.
RESULTS:
Patency could be evaluated only at the dorsum of the foot, ankle, and lower leg because the near-infrared
rays emitted by the special camera used could not penetrate the deep subcutaneous layer containing
collective lymphatics in areas such as the thigh. Several patterns were observed on fluorescence
lymphography: straight, radial, and L-shaped. Cumulative patency rates of LVSEAs were 75% at 12
months and 36% at 24 months after surgery. No significant difference in volume change of the affected limb
was seen between the 34 patients with patent anastomosis (600 ± 969 mL) and the 24 patients without
obvious evidence of patency (420 ± 874 mL).
CONCLUSIONS:
Although further study is required to determine factors leading to anastomotic obstruction and to optimize
the results of microlymphatic surgery, the present LVSEA technique appears promising.
Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.
PMID: 22209609 [PubMed - as supplied by publisher]
Case Rep Dermatol. 2011 Sep;3(3):251-8. Epub 2011 Nov 30.
A case of yellow nail syndrome with dramatically improved nail discoloration by oral clarithromycin.
Suzuki M, Yoshizawa A, Sugiyama H, Ichimura Y, Morita A, Takasaki J, Naka G, Hirano S, Izumi S,
Takeda Y, Hoji M, Kobayashi N, Kudo K.
Source
Department of Respiratory Medicine, National Center for Global Health and Medicine, Infection, Oncology,
Nippon Medical School, Tokyo.
Abstract
An 80-year-old woman was admitted to our hospital with pneumonia and exacerbation of sinobronchial
syndrome (SBS). She presented with yellow discoloration of the nail beds of all fingers and toes, and her
nails were recognized as growing slowly. Chest X-ray revealed bronchiectasis in the bilateral lower lobe and
bilateral pleural effusion. We diagnosed her as having yellow nail syndrome (YNS), based on the triad of
yellow nails, lymphedema, and lung disease. After treatment with antibiotics [ampicillin/sulbactam and
clarithromycin (CAM)] for pneumonia and SBS, her general condition improved, and the yellow nails
disappeared in some fingers. When she was previously treated with 200 mg CAM for SBS, her yellow nails
had not shown improvement. This time, her yellow nails improved after treatment with 400 mg CAM. The
literature reports vitamin E, zinc, and topical corticosteroid plus active vitamin D3 to be effective in the
treatment of yellow nails. Two studies have reported treatment for YNS using CAM, though they found a
lack of efficacy. Thus, the present case is the first to report improved yellow nails using CAM alone. We
conclude that not only SBS and lung disease but also YNS were improved by treatment with 400 mg CAM.
PMID: 22220146 [PubMed - in process] PMCID: PMC3250669
BMC Cancer. 2012 Jan 4;12(1):6. [Epub ahead of print]
Systematic review: conservative treatments for secondary lymphedema.
Oremus M, Dayes I, Walker K, Raina P.
Abstract
ABSTRACT:
BACKGROUND:
Several conservative (i.e., nonpharmacologic, nonsurgical) treatments exist for secondary lymphedema. The
optimal treatment is unknown. We examined the effectiveness of conservative treatments for secondary
lymphedema, as well as harms related to these treatments.
METHODS:
We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, AMED, and
CINAHL from 1990 to January 19, 2010. We obtained English- and non-English-language randomized
controlled trials or observational studies (with comparison groups) that reported primary effectiveness data
on conservative treatments for secondary lymphedema. For English-language studies, we extracted data in
tabular form and summarized the tables descriptively. For non-English-language studies, we summarized the
results descriptively and discussed similarities with the English-language studies.
RESULTS:
Thirty-six English-language and eight non-English-language studies were included in the review. Most of
these studies involved upper-limb lymphedema secondary to breast cancer. Despite lymphedema's
chronicity, lengths of follow-up in most studies were under six months. Many trial reports contained
inadequate descriptions of randomization, blinding, and methods to assess harms. Most observational
studies did not control for confounding. Many studies showed that active treatments reduced the size of
lymphatic limbs, although extensive between-study heterogeneity in areas such as treatment comparisons and
protocols, and outcome measures, prevented us from assessing whether any one treatment was superior.
This heterogeneity also precluded us from statistically pooling results. Harms were rare (<1% incidence) and
mostly minor (e.g., headache, arm pain).
CONCLUSIONS:
The literature contains no evidence to suggest the most effective treatment for secondary lymphedema.
Harms are few and unlikely to cause major clinical problems.
PMID: 22216837 [PubMed - as supplied by publisher]
January 15, 2012
J Rehabil Res Dev. 2011;48(10):1261-8.
Effect of home-based exercise program on lymphedema and quality of life in female postmastectomy
patients: Pre-post intervention study.
Gautam AP, Maiya AG, Vidyasagar MS.
Source
Department of Physiotherapy, Manipal College of Allied Health Sciences, Manipal University, Manipal-
576104, Karnataka, India. Email: ajayphysio@gmail.com. ajay78gmpt@yahoo.co.in.
Abstract
Lymphedema is a debilitating complication following mastectomy, affecting the arm functions and quality of
life (QOL) of breast cancer patients. Studies have shown the beneficial effects of upper-limb exercises on
lymphedema in clinical set tings. However, there is a dearth of evidence regarding the effect of home-based
exercises on lymphedema; therefore, we examined the effect of a home-based exercise program on
lymphedema and QOL in postmastectomy patients. Thirty-two female postmastectomy lymphedema
patients participated in an individualized home-based exercise program for 8 weeks. Arm circumference,
arm volume, and QOL (36-Item Short Form Health Survey) were measured before and after the program.
Data were analyzed with the use of paired t-tests for circumferential and volumetric measures and Wilcoxon
signed ranks tests for QOL. Significance level was set at p < 0.01 with Bonferroni correction (alpha/n = 0.05
/5 = 0.01). Analysis showed a statistically significant improvement in the affected upper-limb circumference
and volume (~122 mL reduction, p < 0.001) and in the QOL scores (p < 0.001) at the end of the home-
based exercise program. The individualized home-based exercise program led to improvement in affected
upper-limb volume and circumference and QOL of postmastectomy lymphedema patients.
PMID: 22234669 [PubMed - in process]
Ann Surg. 2012 Jan 9. [Epub ahead of print]
Microvascular Breast Reconstruction and Lymph Node Transfer for Postmastectomy Lymphedema Patients.
Saaristo AM, Niemi TS, Viitanen TP, Tervala TV, Hartiala P, Suominen EA.
Source
From the Department of Plastic Surgery, Turku University Central Hospital, Turku, Finland.
Abstract
OBJECTIVE:
Postoperative lymphedema after breast cancer surgery is a challenging problem. Recently, a novel
microvascular lymph node transfer technique provided a fresh hope for patients with lymphedema. We
aimed to combine this new method with the standard breast reconstruction.
METHODS:
During 2008-2010, we performed free lower abdominal flap breast reconstruction in 87 patients. For all
patients with lymphedema symptoms (n = 9), we used a modified lower abdominal reconstruction flap
containing lymph nodes and lymphatic vessels surrounding the superficial circumflex vessel pedicle.
Operation time, donor site morbidity, and postoperative recovery between the 2 groups (lymphedema
breast reconstruction and breast reconstruction) were compared. The effect on the postoperative lymphatic
vessel function was examined.
RESULTS:
The average operation time was 426 minutes in the lymphedema breast reconstruction group and 391
minutes in the breast reconstruction group. The postoperative abdominal seroma formation was increased in
patients with lymphedema. Postoperative lymphoscintigraphy demonstrated at least some improvement in
lymphatic vessel function in 5 of 6 patients with lymphedema. The upper limb perimeter decreased in 7 of 9
patients. Physiotherapy and compression was no longer needed in 3 of 9 patients. Importantly, we found
that human lymph nodes express high levels of endogenous lymphatic vessel growth factors. Transfer of the
lymph nodes and the resulting endogenous growth factor expression may thereby induce the regrowth of
lymphatic network in the axilla. No edema problems were detected in the lymph node donor area.
CONCLUSION:
Simultaneous breast and lymphatic reconstruction is an ideal option for patients who suffer from
lymphedema after mastectomy and axillary dissection.
PMID: 22233832 [PubMed - as supplied by publisher]
Int Angiol. 2011 Dec;30(6):527-33.
Dose finding for an optimal compression pressure to reduce chronic edema of the extremities.
Partsch H, Damstra RJ, Mosti G.
Source
Private Practictioner, Vienna, Austria - hugo.partsch@meduniwien.ac.at.
Abstract
AIM:
The optimal pressure to reduce chronic extremity swelling is still a matter of debate. The aim of this paper
was to measure volume reduction of a swollen extremity depending on the amount of pressure exerted by
compression stockings and inelastic bandages.
METHODS:
Thirty-six patients with unilateral breast cancer related arm lymphedema were investigated in a lymph clinic
in the Netherlands, 42 legs with chronic edema of the lower extremities were examined in a phlebological
centre in Italy. The arm-patients were randomized to receive inelastic arm bandages with a pressure
between 20-30 mmHg or 44-68 mmHg. The leg patients were either treated with compression stockings
(23-32 mmHg) or with inelastic bandages (pressure 53-88 mmHg). Water-displacement volumetry and
measurement of leg circumference was performed before and after compression.
RESULTS:
In the arm-patients low pressure after 2 hours achieved a higher degree of volume reduction (-2.3%, 95%
CI 1.0-3.6) than high pressure (-1.5%, 95% CI 0.2-2.8) (n.s.). In patients with leg edema compression
stockings in the range between 20 and 40 mmHg showed a positive correlation between exerted pressure
and volume reduction, bandages applied with an initial resting pressure of more than 60 mm Hg resulted in a
decreasing volume reduction.
CONCLUSION:
There is obviously an upper limit beyond which further increase of compression pressure seems
counterproductive. For inelastic bandages this upper limit is around 30 Hg on the upper and around 50-60
mmHg on the lower extremity.
PMID: 22233613 [PubMed - in process]
Int Angiol. 2011 Dec;30(6):499-503.
The lymphovenous microsurgical shunts for treatment of lymphedema of lower limbs: indications in 2011.
Olszewski WL.
Source
Department of Surgical Research and Transplantology, Medical Research Center, Polish Academy of
Sciences, Warsaw, Poland - wlo@cmdik.pan.pl.
Abstract
The microsurgical lympho-venous shunts have become one of the generally accepted modalities in treatment
of limb lymphedema. This review highlight the indications for this procedure after over 40 years. This study
was based on the personal experience of one surgeon and on the review of the literature. Patients with
postinflammatory, postsurgical, idiopathic and hyperplastic lymphedema of lower limbs were included in the
study. Basing on the review of results of the last 40 years the contemporary indications are: 1) lymphedema
with local segmental obstruction but still partly patent distal lymphatics seen on functional lymphoscintigraphy
(standard walking or pneumatic compression) and without an active inflammatory process in the skin,
subcutaneous tissue and lymph vessels (DLA-dermatolymphangioadenitis); 2) classified according the
etiology of lymphedema, this operation can bring about satisfactory results in cases of hyperplastic,
postsurgical and postinflammatory types of lymphedema, whereas primary idiopathic lymphedema of non-
genetic type should be treated with conservative means, although in a small number of cases an improvement
was observed after lympho-venous shunting as long as 10 years. Microsurgical lymph node or lymphatic
vessel to vein shunts have their established position among the therapy modalities for lymphedema of lower
limbs in a strictly defined group of patients using lymphoscintigraphic imaging.
PMID: 22233610 [PubMed - in process]
J Obstet Gynaecol Res. 2012 Jan 10. doi: 10.1111/j.1447-0756.2011.01727.x. [Epub ahead of print]
Re-consideration of lymphadenectomy for stage Ib1 cervical cancer.
Kato H, Todo Y, Suzuki Y, Ohba Y, Minobe SI, Okamoto K, Yamashiro K, Sakuragi N.
Source
Divisions of Gynecologic Oncology Pathology, National Hospital Organization, Hokkaido Cancer Center,
Department of Obstetrics and Gynaecology, Hokkaido University School of Medicine, Sapporo, Japan.
Abstract
Aim: Because of less frequent lymph node metastasis and parametrial involvement, patients with stage Ib1
cervical cancer may benefit from a curtailment of surgery. We retrospectively investigated the distribution of
lymph node metastasis in stage Ib1 patients. After comparing the data with that of higher stages and sentinel
lymph node navigation (SLNN), the appropriate extent of lymphadenectomy (LA) in stage Ib1 disease was
newly suggested. Method: A total of 303 patients underwent a radical hysterectomy with LA and the
region-specific rate of node metastasis was obtained. SLNN was performed for 50 patients using (99m) Tc
phytate injection into the cervix and intra-operative detection by a gamma-probe. Results: The rate of node
metastasis and the average number of nodes removed, respectively, were: 23/189 (12.2%), 65.2 in stage
Ib1; 14/47 (29.8%), 70.1 in stage Ib2; 7/20 (35.0%), 78.2 in stage IIa; and 26/47 (55.3%), 69.1 in stage
IIb. Lymph node metastasis in stage Ib1 was prevalent in the obturator (Ob) (9.5%), inter-iliac (Ii) (4.9%),
superficial common iliac (Sc) (2.3%), cardinal (Cd) (2.2%) and external iliac (Ei) (1.7%) nodes. In patients
with upper stage disease, lymph node metastasis could occur in all lymph nodes. In stage Ib1 patients, the
sentinel nodes were assigned only to the Ob, Ii, Sc and Ei nodes, being identical with frequent metastatic
sites in stage Ib1 (excluding Cd). Conclusion: The extent of LA can be routinely completed with the
removal of Ob, Ii, Ei, Sc and Cd nodes, which may provide a higher quality of life, including the reduction of
lymphedema by preventing the removal of the inguinal nodes.
© 2012 The Authors. Journal of Obstetrics and Gynaecology Research © 2012 Japan Society of
Obstetrics and Gynecology.
PMID: 22229927 [PubMed - as supplied by publisher]
January 19, 2012
Br J Community Nurs. 2011 Oct;16 Suppl:S4-S12.
Use of compression bandaging in managing chronic oedema.
Todd M.
Abstract
Compression bandaging is a major component of most community nurses' practice in the management of
venous leg ulcers. For lymphoedema practitioners, compression therapy is the linchpin in the management of
chronic oedema and lymphoedema. There are several types of compression bandage available, with some
being part of a recognized system of compression delivery. In order for nurses to select and apply the
correct type and level of compression bandaging, there needs to be a substantial level of knowledge of the
principles of compression theory and competence in the application of bandaging. There are also issues
surrounding patient concordance, and nurses need to be able to assess and address any barriers to
concordance to ensure the most effective regimen of treatment is delivered.
PMID: 22240574 [PubMed - in process]
Br J Community Nurs. 2011 Oct;16 Suppl:S28-9.
An interview with Karen Morgan.
Morgan K.
Abstract
Karen Morgan is Lymphoedema Clinical Nurse Specialist, Abertawe Bro Morgannwg University Health
Board (ABMUHB) Lymphoedema
Health Board (ABMUHB) Lymphoedema Clinic.
PMID: 22240571 [PubMed - in process]
Br J Community Nurs. 2011 Oct;16 Suppl:S22-7.
An integrative treatment for lower limb lymphoedema in India.
Bose KS, Aggithaya GM.
Abstract
Lymphoedema is a chronic disease which requires frequent visits to therapist in developed countries. In most
developing countries, it is the disease of rural area caused by lymphatic filariasis (LF). The aim is to develop
a low cost home-based self-care protocol using the combinations of locally available treatment modalities.
The integrated treatment has the elements of therapy from modern dermatology, Ayurveda and yoga,
administered by the doctors of respective system of medicine on the basis of pathophysiological
understanding in lymphology. The sequence of treatment components that each patient followed is skin
wash, soaking the limb in herbal Phanta solution, care of bacterial entry points, a set of yoga exercises,
Indian manual lymph drainage and compression bandaging. A total of 1209 limbs in 889 patients were
treated using integrated medicine during October 2004-May 2011. All patients received an initial 14 days of
supervised treatment and training for self-care and home-based treatment to be continued for life. Patients
followed up twice. Volume reduction for large sized limbs at 3 months following treatment was 41.1%, with
a confidence interval (CI) of 5.7-6.9 litres. Reduction was 25.7 % for small limbs with a CI of 1.5-1.7 litres.
Entry points were present in 86.2% limbs at baseline and in 71.7% limbs at the end of 3 months.
Inflammatory episodes reduced from 80%-8.6%.
PMID: 22240570 [PubMed - in process]
Br J Community Nurs. 2011 Oct;16 Suppl:S20-1.
Lymphangioma or lymphangiectasia? An update for lymphoedema nurses.
Pike C.
Abstract
This article is prompted by a recent enquiry to the British Lymphology Society, expressing uncertainty over
the definition of lymphangioma. It may be prudent to publicize information on this potentially confusing area
more widely, as clinicians need to know what lymphangioma is, or is not.
PMID: 22240569 [PubMed - in process]
Br J Community Nurs. 2011 Oct;16 Suppl:S14-9.
Non-concordance in lymphorrhea of the lower limbs: a case study.
Jones J.
Abstract
Obesity and a sedentary lifestyle are fast becoming major problems for not only the NHS as a whole but
also the lymphoedema therapist. Lymphorrhea in this group of patients can be a recurrent problem, causing
strain on already stretched services and on the patient and their family. What happens when the ideas of the
patient and therapist regarding treatment are not the same? This article aims to address these issues by
looking at a case study of such a patient, and the surprising outcome that resulted when the patient got his
own way.
PMID: 22240568 [PubMed - in process]
January 22, 2012,
Br J Community Nurs. 2011 Oct;16 Suppl:S22-7.
An integrative treatment for lower limb lymphoedema in India.
Bose KS, Aggithaya GM.
Abstract
Lymphoedema is a chronic disease which requires frequent visits to therapist in developed countries. In most
developing countries, it is the disease of rural area caused by lymphatic filariasis (LF). The aim is to develop
a low cost home-based self-care protocol using the combinations of locally available treatment modalities.
The integrated treatment has the elements of therapy from modern dermatology, Ayurveda and yoga,
administered by the doctors of respective system of medicine on the basis of pathophysiological
understanding in lymphology. The sequence of treatment components that each patient followed is skin
wash, soaking the limb in herbal Phanta solution, care of bacterial entry points, a set of yoga exercises,
Indian manual lymph drainage and compression bandaging. A total of 1209 limbs in 889 patients were
treated using integrated medicine during October 2004-May 2011. All patients received an initial 14 days of
supervised treatment and training for self-care and home-based treatment to be continued for life. Patients
followed up twice. Volume reduction for large sized limbs at 3 months following treatment was 41.1%, with
a confidence interval (CI) of 5.7-6.9 litres. Reduction was 25.7 % for small limbs with a CI of 1.5-1.7 litres.
Entry points were present in 86.2% limbs at baseline and in 71.7% limbs at the end of 3 months.
Inflammatory episodes reduced from 80%-8.6%.
PMID: 22240570 [PubMed - in process]
January 22, 2012
J Cancer Surviv. 2012 Jan 13. [Epub ahead of print]
Community-based exercise program effectiveness and safety for cancer survivors.
Rajotte EJ, Yi JC, Baker KS, Gregerson L, Leiserowitz A, Syrjala KL.
Source
Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, D5-220, P.
O. Box 19024, Seattle, WA, 98109, USA.
Abstract
PURPOSE:
Clinical trials have demonstrated the benefits of exercise for cancer survivors. This investigation determined
the effectiveness and safety of a disseminated community-based exercise program for cancer survivors who
had completed treatment.
METHODS:
Personal trainers from regional YMCAs received training in cancer rehabilitation and supervised twice-a-
week, 12-week group exercise sessions for survivors. At baseline and post-program, validated measures
assessed patient-reported outcomes (PRO) and physiologic measurements.
RESULTS:
Data were collected from 221 survivors from 13 YMCA sites and 36 separate classes. All participants had
data available at one time point, while matched baseline and post-program PRO and physiologic data were
available for 85% (N = 187). Participants with matched data were largely female (82%), with mean age of
58 (range, 28-91 years). Time since diagnosis ranged from 1 to 48 (mean, 5.6 years), and mean time since
last treatment was 3.0 (range, 1-33 years). Physiological improvements were significant in systolic (P <
0.001) and diastolic (P = 0.035) blood pressure, upper and lower body strength, the 6-min walk test (P =
0.004), and flexibility (P < 0.001). Participants reported improvements in overall health-related quality of life
(P < 0.001), social support (P = 0.019), body pain (P = 0.016), fatigue (P < 0.001), insomnia (P < 0.001),
and overall musculoskeletal symptoms (P = <0.001). Few injuries or lymphedema events occurred during
classes.
CONCLUSIONS:
Community-based exercise groups for cancer survivors of mixed diagnoses and ages, who have completed
active treatment, have physiologic and psychosocial benefits, and are safe. IMPLICATIONS FOR
CANCER SURVIVORS: Survivors may expect significant benefit from participating in a community-based
exercise program tailored to meet their individual needs as a survivor.
PMID: 22246463 [PubMed - as supplied by publisher]
Hematol Oncol Clin North Am. 2012 Feb;26(1):169-94. Epub 2011 Dec 16.
Contemporary quality of life issues affecting gynecologic cancer survivors.
Carter J, Penson R, Barakat R, Wenzel L.
Source
Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
10065, USA; Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York,
NY 10065, USA.
Abstract
Regardless of cancer origin or age of onset, the disease and its treatment can produce short- and long-term
sequelae (ie, sexual dysfunction, infertility, or lymphedema) that adversely affect quality of life (QOL). This
article outlines the primary contemporary issues or concerns that may affect QOL and offers strategies to
offset or mitigate QOL disruption. These contemporary issues are identified within the domains of sexual
functioning, reproductive issues, lymphedema, and the contribution of health-related QOL in influential
gynecologic cancer clinical trials.
Copyright © 2012 Elsevier Inc. All rights reserved.
PMID: 22244668 [PubMed - in process]
MEDNEWS DOCS:
January 3, 2012
New Treatment Direction For Rare Metabolic Diseases
A research team led by biochemist Scott Garman at the University of Massachusetts Amherst has
discovered a key interaction at the heart of a promising new treatment for a rare childhood metabolic
disorder known as Fabry disease. The discovery will help understanding of other protein-folding disorders
such as Alzheimer's, Parkinson's and Huntington's diseases, as well. Findings are featured as the cover story
in the current issue of Chemistry & Biology.
People born with Fabry disease have a faulty copy of a single gene that codes for the alpha-galactosidase (α-
GAL) enzyme, one of the cell's "recycling" machines. When it performs normally, α-GAL breaks down an
oily lipid known as GB3 in the cell's recycling center, or lysosome. But when it underperforms or fails, Fabry
symptoms result. Patients may survive to adulthood, but the disorder leads to toxic lipid build-up in blood
vessels and organs that compromise kidney function or lead to heart disease, for example.
The faulty gene causes its damage by producing a misfolded protein, yielding an unstable, poorly functioning
α-GAL enzyme. Like origami papers, these proteins are unfolded to start and only become active when
folded into precise shapes. At present, enzyme replacement therapy (ERT) is the only FDA-approved
treatment for such lysosomal storage disorders as Fabry, Pompe and Gaucher diseases, but ERT requires a
complicated and expensive process to purify and replace the damaged α-GAL enzyme, and it must be
administered by a physician.
Instead of replacing the damaged enzyme, an alternative route called pharmacological chaperone (PC)
therapy is currently in Phase III clinical trials for Fabry disease. It relies on using smaller, "chaperone"
molecules to keep proteins on the right track toward proper folding, but their biochemical mechanism is not
well understood, says Garman.
Now, he and colleagues report results of a thorough exploration at the atomic level of the biochemical and
biophysical basis of two small molecules for potentially stabilizing the α-GAL enzyme. He says their use in
PC therapy could one day be far less expensive than the current standard, ERT, and can be taken orally.
This work, which improves knowledge of a whole class of molecular chaperones, represents the centerpiece
of UMass Amherst student Abigail Guce's doctoral thesis and was supported by the National Institutes of
Health. Other members of the team are graduate students Nat Clark and Jerome Rogich.
"The interactions we looked at are exactly the things occurring in the clinical trial right now," Garman says.
Further, "the same concept is now being applied to other protein-folding diseases such as Parkinson's and
Alzheimer's disease. Many medical researchers are trying to keep proteins from misfolding by using small
chaperone molecules. Our studies have definitely advanced the understanding of how to do that."
In their current paper, Garman and colleagues compare the ability of two small chaperone molecules,
galactose and 1-deoxygalactononjirimycin (DGJ) to stabilize the α-GAL protein, to help it resist unfolding in
different conditions such as high temperature and different pH levels.
They found that each chaperone has very different affinities: DGJ binds tightly and galactose binds loosely to
the α-GAL, yet they differ in only two atomic positions. "Tight is better, because you can use less drug for
treatment," Garman says. "We now can explain DGJ's high potency, its tight binding, down to individual
atoms."
In earlier studies as in the current work, the UMass Amherst team used their special expertise in X-ray
crystallography to create three-dimensional images of all atoms in the protein to understand how it carries
out its metabolic mission. They also found a new binding site for small molecules on human α-GAL that had
never been observed before.
Crystallography on the two chaperones bound to the α-GAL enzyme showed that a single interaction
between the enzyme and DGJ was responsible for DGJ's high affinity for the enzyme. Other experiments
also showed the ability of the 11- and 12-atom chaperones to protect the large, 6,600-atom α-GAL from
unfolding and degradation.
For the first time, by making a single change in one amino acid in protein, they forced the DGJ to bind
weakly, indicating that one atomic interaction is responsible for DGJ's high affinity.
"It was surprising to find these two small molecules that look very much the same have very different
affinities for this enzyme," says Garman, "and we now understand why. The iminosugar DGJ has high
potency due to a single ionic interaction with α-GAL. Overall, our studies show that this small molecule
keeps the enzyme from unfolding, or when it unfolds, the process happens more slowly, all of which you
need in treating disease."
The UMass Amherst team plans to next use the principles, assays and experiments they developed here on
enzymes defective in other human diseases to examine new therapies for them and related disorders.
JANUARY 9, 2012
Significant Cost Savings Associated With Emergence Of Prospective Surveillance Model As Standard Of
Care For Breast Cancer Treatment
Early diagnosis and treatment of breast cancer-related lymphedema by a physical therapist can significantly
reduce costs and the need for intensive rehabilitation, according to an article published in the January issue of
Physical Therapy (PTJ), the scientific journal of the American Physical Therapy Association (APTA).
The study, led by APTA member and spokesperson Nicole Stout, PT, MPT, CLT-LANA, compared a
prospective surveillance model with a traditional model of impairment-based care and examined the direct
treatment costs associated with each program. Treatment and supply costs were estimated based on the
Medicare 2009 physician fee schedule. Researchers estimated that treatment for breast cancer-related
lymphedema costs $636.19 a year when the prospective surveillance model was used vs $3,124.92 for
traditional treatment of advanced lymphedema.
The goal of a prospective surveillance model for cancer rehabilitation is to identify impairment at the earliest
onset to alleviate impairment or prevent it from progressing. Soon after diagnosis, a physical therapist will
perform a preoperative examination to establish a baseline level of function. Follow-up examinations are then
conducted postoperatively at 1 month and then 3-month intervals, for up to 1 year. In contrast, a traditional
model focuses on treating lymphedema once it has progressed and patients already have functional
limitations.
"This study begins to paint a picture of evidence showing that prevention of chronic conditions such as
lymphedema - using rehabilitation models of care - may result in significant cost savings," said Stout.
Breast cancer-related lymphedema is characterized by abnormal swelling of the arm and hand, which can be
disfiguring. A chronic condition, it is associated with decreased arm function, disability, and diminished
quality of life. If the condition is not diagnosed early and managed, a patient can be at risk for infection and
further shoulder complications.
In place for more than 10 years, the prospective surveillance model was developed at the National Naval
Medical Center in Bethesda - now part of the Walter Reed National Military Medical Center - and is the
standard of care for all patients diagnosed with breast cancer at the medical center. Several research articles
have been published demonstrating clinical effectiveness of the prospective surveillance model in reducing
lymphedema, shoulder morbidity, and fatigue, including the February 2010 article in the journal Breast
Cancer Research and Treatment.
Although further analysis of indirect costs and utility is necessary to fully assess cost effectiveness, the
prospective surveillance model is emerging as the standard of care for breast cancer treatment.
January 15, 2012
New, Noninvasive Way To Identify Lymph Node Metastasis
Using two cell surface markers found to be highly expressed in breast cancer lymph node metastases,
researchers at Moffitt Cancer Center, working with colleagues at other institutions, have developed targeted,
fluorescent molecular imaging probes that can non-invasively detect breast cancer lymph node metastases.
The new procedure could spare breast cancer patients invasive and unreliable sentinel lymph node (SLN)
biopsies and surgery-associated negative side effects.
Their study was published in a recent issue of Clinical Cancer Research (18:1), a publication of the
American Association for Cancer Research.
"The majority of breast cancer patients, up to 74 percent, who undergo SLN biopsy are found to be
negative for axillary nodal, or ALN, metastases," said corresponding author David L. Morse, Ph.D., an
associate member at Moffitt whose research areas include experimental therapeutics and diagnostic imaging.
"Determining the presence or absence of ALN metastasis is critical to breast cancer staging and prognosis.
Because of the unreliability of the SLN biopsy and its potential for adverse effects, a noninvasive, more
accurate method to assess lymph node involvement is needed."
The authors note that the postoperative complications to the SLN biopsy can include lymphedema, seroma
formation, sensory nerve injury and limitations in patient range of motion. In addition, biopsies fail to identify
disease in axillary lymph nodes in five to 10 percent of patients.
In developing targeted molecular probes to identify breast cancer in axillary lymph nodes, the research team
from Moffitt, the University of Arizona and University of Florida used two surface cell markers - CAIX and
CAXII. CAIX is a cell surface marker known to be "highly and broadly expressed in breast cancer lymph
node metastases" and absent in normal tissues.
CAIX and CAXII are both integral plasma membrane proteins with large extracellular components that are
accessible for binding of targeted imaging probes, explained Morse. In addition, several studies have shown
that CAIX expression is associated with negative prognosis and resistance to chemo and radiation therapy
for breast cancer. CAXII is a protein expressed in over 75 percent of axillary lymph node metastases.
The researchers subsequently developed their targeting agents by using monoclonal antibodies specific for
binding CAIX and CAXII, both of which are known to promote tumor growth.
According to the researchers, a number of noninvasive optical imaging procedures for SLN evaluation have
been investigated, but the approaches have lacked the ability to target tumor metastasis biomarkers.
"These methods provide only anatomic maps and do not detect tumor cells present in lymph nodes,"
explained Morse. "Using mouse models of breast cancer metastasis and a novel, monoclonal anti-body-
based molecular imaging agents, we developed a targeted, noninvasive method to detect ALN metastasis
using fluorescence imaging."
In addition to the imaging study with mice, the researchers also reported that the combination of CAIX and
CAXII covered 100 percent of patient-donated samples used in their tissue microarray (TMA) study.
"The imaging probes detected tumor cells in ALNs with high sensitivity," explained Morse. "Either CAIX or
CAXII were expressed in 100 percent of the breast cancer lymph node metasatsis samples we surveyed in
this study. These imaging probes have potential for providing a noninvasive way to stage breast cancer in the
clinic without unneeded and costly surgery."
J Mal Vasc. 2011 Dec 21. [Epub ahead of print]
[Designing a therapeutic education program for patients with lymphedema: Live with lymphedema.]
[Article in French]
Blaise S, Villemur B, Richaud C, Rastel D, Bucci B, Evra V, Bouchet JY; les membres du réseau
GRANTED, Satger B.
Source
Department of Vascular Medicine, clinique de médecine vasculaire, Grenoble University Hospital, BP 217,
38043 Grenoble cedex 09, France; Réseau GRANTED, 38400 Saint-Martin-d'Hères, France.
Abstract
BACKGROUND:
Lymphedema is a chronic condition considered to be rare in its primary form and potentially frequent in
women after breast surgery for cancer: 27,000new cases annually. Therapeutic management is a serious
challenge. In France, the health authorities (Haute Autorité de santé [HAS]) have recently proposed that
appropriate management practices for lymphedema include "patient education". The HAS and the National
institute for health care prevention and education also published a methodology guide devoted to structuring
a therapeutic education program for patients with chronic disease. Current hospital regulations state that this
education program is part of the care to be delivered to patients with chronic disease and that it must comply
with the national directives. The purpose of our present work was to present the concept and the contents of
a patient education program entitled "Live with lymphedema" designed for patients with lymphedema and
developed within the inpatient-outpatient network GRANTED in Sud-Isère.
METHODS:
A standard detailed educative approach was applied. It was designed after the educational program for
patients with lower limb arterial occlusive disease authorized by the Rhône-Alpes regional health agency. It
was adapted to the specific problematic of patients with lymphedema, including medical management,
rehabilitation, dermatology and nutritional aspects. It was developed in cooperation with patients and favors
local associative actions.
RESULTS:
The specifically structured program included three therapeutic education consultations and five workshops.
Less than one year after its institution, more than 30 patients have participated in the program.
DISCUSSION:
We report a structured patient education program designed for patients with lymphedema. This program
was authorized by the Rhône-Alpes regional health agency in March 2011and is in compliance with the
national directives and HAS guidelines.
Copyright © 2011 Elsevier Masson SAS. All rights reserved.
PMID: 22196687 [PubMed - as supplied by publisher]
January 9, 2012
J Cutan Pathol. 2012 Jan;39(1):52-5. doi: 10.1111/j.1600-0560.2011.01785.x.
Lymphangiosarcoma arising after 33 years within a background of chronic filariasis: a case report with
review of literature.
Krishnamoorthy N, Viswanathan S, Rekhi B, Jambhekar NA.
Source
Department of Pathology, Tata Memorial Hospital, Mumbai, India.
Abstract
Cutaneous angiosarcoma or lymphangiosarcoma represents an uncommon aggressive tumor known to arise
on a background of chronic lymphedema secondary to various etiologies, principally following surgery or
irradiation. There have been rarely reported cases of angiosarcoma following infective conditions that
eventuate with lymphatic stasis. We report a case of angiosarcoma arising after 33 years within a
background of filariasis. Awareness of this association can lead to early diagnosis and appropriate treatment
of this potentially fatal malignant tumor. Krishnamoorthy N, Viswanathan S, Rekhi B, Jambhekar NA.
Lymphangiosarcoma arising after 33 years within a background of chronic filariasis: a case report with
review of literature.
Copyright © 2011 John Wiley & Sons A/S.
PMID: 22211335 [PubMed - in process]
Med Oncol. 2011 Dec;28 Suppl 1:22-30. Epub 2010 Sep 9.
Whether drainage should be used after surgery for breast cancer? A systematic review of randomized
controlled trials.
He XD, Guo ZH, Tian JH, Yang KH, Xie XD.
Source
Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, No. 199
Donggang West Road, Lanzhou, Gansu, 730000, China, hxdls58@163.com.
Abstract
A systematic review of randomized controlled trials (RCTs) was conducted to evaluate whether patients
benefit from the suction drainage after axillary lymph node dissection (ALND) in breast cancer surgery.
RCTs of drainage versus no drainage after ALND in women with breast cancer were retrieved from
PubMed, EMBASE, Cochrane Library and Chinese Biomedical database. Two authors independently
assessed the quality of included trials and extracted data. Odds ratio (OR) for dichotomous outcomes and
mean difference (MD) for continuous outcomes were presented with 95% confidence intervals (CI). A total
of 1115 titles were indentified from the databases; 1109 obvious irrelevant studies were excluded by
examining the titles, abstracts, full texts because of duplicates, no RCT, different modality of drainage, drain
for lymphedema, application of fibrin sealant and so on. And then, only 6 RCTs to compare drainage with
no drainage after ALND in breast cancer surgery were included in the systematic review and a total of 585
patients were included in the pathological diagnosis of breast cancer in women before surgery, management
by ALND with or without addition surgical procedures. The study demonstrated that insertion of a drain in
the axilla after breast cancer surgery resulted in a statistically significant reduction in the rate of seroma (OR
= 0.36, 95% CI, 0.16 to 0.81, P = 0.01), the volume of aspiration (MD = -100.10, 95% CI, -174.36 to
-25.85, P = 0.008), or the frequency of seroma aspiration (MD = -1.03, 95% CI, -1.35 to -0.71, P <
0.00001), but prolonged the length of hospital stay (MD = 1.52, 95% CI, 0.36 to 2.68, P = 0.01). There
was no statistically significant difference in the incidence of wound infection (OR = 0.67, 95% CI, 0.34 to
1.32, P = 0.25) between drainage group and no drainage group. Based on the current evidence, insertion of
a drain in the axilla following ALND in breast cancer surgery effectively decreased seroma formation,
volume of aspiration as well as the frequency of seroma aspiration without increasing the incidence of wound
infection, but extending their stay in hospital.
PMID: 20827578 [PubMed - in process]
J Vasc Surg. 2011 Dec 29. [Epub ahead of print]
Technique, results, and postoperative patency of lymphaticovenous side-to-end anastomosis in peripheral
lymphedema.
Maegawa J, Yabuki Y, Tomoeda H, Hosono M, Yasumura K.
Source
Department of Plastic and Reconstructive Surgery, Yokohama City University Hospital, Yokohama, Japan.
Abstract
OBJECTIVE:
Lymphaticovenous anastomosis has been used for patients with peripheral lymphedema. However, the
efficacy of this procedure is controversial due to a lack of evidence regarding postoperative patency. We
sought to determine midterm postoperative patency of lymphaticovenous side-to-end anastomoses
(LVSEAs) using indocyanine green fluorescence lymphography.
METHODS:
This was a retrospective observational study set in a teaching hospital. Of 107 patients with chronic
lymphedema who underwent 472 LVSEAs, 57 (223 anastomoses) consented to fluorescence
lymphography and comprised the study cohort. The intervention consisted of a microsurgical LVSEA
performed with a suture-stent method. Patients also had preoperative and postoperative complex
decongestive physiotherapy. Anastomosis patency was assessed using indocyanine green fluorescence
lymphography ≥6 months after surgery. Patency rates were calculated using Kaplan-Meier analysis. We
assessed volume reduction on the operated-on limb and compared this between patients in whom
anastomoses were patent and those in whom anastomoses were not obviously patent.
RESULTS:
Patency could be evaluated only at the dorsum of the foot, ankle, and lower leg because the near-infrared
rays emitted by the special camera used could not penetrate the deep subcutaneous layer containing
collective lymphatics in areas such as the thigh. Several patterns were observed on fluorescence
lymphography: straight, radial, and L-shaped. Cumulative patency rates of LVSEAs were 75% at 12
months and 36% at 24 months after surgery. No significant difference in volume change of the affected limb
was seen between the 34 patients with patent anastomosis (600 ± 969 mL) and the 24 patients without
obvious evidence of patency (420 ± 874 mL).
CONCLUSIONS:
Although further study is required to determine factors leading to anastomotic obstruction and to optimize
the results of microlymphatic surgery, the present LVSEA technique appears promising.
Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.
PMID: 22209609 [PubMed - as supplied by publisher]
Case Rep Dermatol. 2011 Sep;3(3):251-8. Epub 2011 Nov 30.
A case of yellow nail syndrome with dramatically improved nail discoloration by oral clarithromycin.
Suzuki M, Yoshizawa A, Sugiyama H, Ichimura Y, Morita A, Takasaki J, Naka G, Hirano S, Izumi S,
Takeda Y, Hoji M, Kobayashi N, Kudo K.
Source
Department of Respiratory Medicine, National Center for Global Health and Medicine, Infection, Oncology,
Nippon Medical School, Tokyo.
Abstract
An 80-year-old woman was admitted to our hospital with pneumonia and exacerbation of sinobronchial
syndrome (SBS). She presented with yellow discoloration of the nail beds of all fingers and toes, and her
nails were recognized as growing slowly. Chest X-ray revealed bronchiectasis in the bilateral lower lobe and
bilateral pleural effusion. We diagnosed her as having yellow nail syndrome (YNS), based on the triad of
yellow nails, lymphedema, and lung disease. After treatment with antibiotics [ampicillin/sulbactam and
clarithromycin (CAM)] for pneumonia and SBS, her general condition improved, and the yellow nails
disappeared in some fingers. When she was previously treated with 200 mg CAM for SBS, her yellow nails
had not shown improvement. This time, her yellow nails improved after treatment with 400 mg CAM. The
literature reports vitamin E, zinc, and topical corticosteroid plus active vitamin D3 to be effective in the
treatment of yellow nails. Two studies have reported treatment for YNS using CAM, though they found a
lack of efficacy. Thus, the present case is the first to report improved yellow nails using CAM alone. We
conclude that not only SBS and lung disease but also YNS were improved by treatment with 400 mg CAM.
PMID: 22220146 [PubMed - in process] PMCID: PMC3250669
BMC Cancer. 2012 Jan 4;12(1):6. [Epub ahead of print]
Systematic review: conservative treatments for secondary lymphedema.
Oremus M, Dayes I, Walker K, Raina P.
Abstract
ABSTRACT:
BACKGROUND:
Several conservative (i.e., nonpharmacologic, nonsurgical) treatments exist for secondary lymphedema. The
optimal treatment is unknown. We examined the effectiveness of conservative treatments for secondary
lymphedema, as well as harms related to these treatments.
METHODS:
We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, AMED, and
CINAHL from 1990 to January 19, 2010. We obtained English- and non-English-language randomized
controlled trials or observational studies (with comparison groups) that reported primary effectiveness data
on conservative treatments for secondary lymphedema. For English-language studies, we extracted data in
tabular form and summarized the tables descriptively. For non-English-language studies, we summarized the
results descriptively and discussed similarities with the English-language studies.
RESULTS:
Thirty-six English-language and eight non-English-language studies were included in the review. Most of
these studies involved upper-limb lymphedema secondary to breast cancer. Despite lymphedema's
chronicity, lengths of follow-up in most studies were under six months. Many trial reports contained
inadequate descriptions of randomization, blinding, and methods to assess harms. Most observational
studies did not control for confounding. Many studies showed that active treatments reduced the size of
lymphatic limbs, although extensive between-study heterogeneity in areas such as treatment comparisons and
protocols, and outcome measures, prevented us from assessing whether any one treatment was superior.
This heterogeneity also precluded us from statistically pooling results. Harms were rare (<1% incidence) and
mostly minor (e.g., headache, arm pain).
CONCLUSIONS:
The literature contains no evidence to suggest the most effective treatment for secondary lymphedema.
Harms are few and unlikely to cause major clinical problems.
PMID: 22216837 [PubMed - as supplied by publisher]
January 15, 2012
J Rehabil Res Dev. 2011;48(10):1261-8.
Effect of home-based exercise program on lymphedema and quality of life in female postmastectomy
patients: Pre-post intervention study.
Gautam AP, Maiya AG, Vidyasagar MS.
Source
Department of Physiotherapy, Manipal College of Allied Health Sciences, Manipal University, Manipal-
576104, Karnataka, India. Email: ajayphysio@gmail.com. ajay78gmpt@yahoo.co.in.
Abstract
Lymphedema is a debilitating complication following mastectomy, affecting the arm functions and quality of
life (QOL) of breast cancer patients. Studies have shown the beneficial effects of upper-limb exercises on
lymphedema in clinical set tings. However, there is a dearth of evidence regarding the effect of home-based
exercises on lymphedema; therefore, we examined the effect of a home-based exercise program on
lymphedema and QOL in postmastectomy patients. Thirty-two female postmastectomy lymphedema
patients participated in an individualized home-based exercise program for 8 weeks. Arm circumference,
arm volume, and QOL (36-Item Short Form Health Survey) were measured before and after the program.
Data were analyzed with the use of paired t-tests for circumferential and volumetric measures and Wilcoxon
signed ranks tests for QOL. Significance level was set at p < 0.01 with Bonferroni correction (alpha/n = 0.05
/5 = 0.01). Analysis showed a statistically significant improvement in the affected upper-limb circumference
and volume (~122 mL reduction, p < 0.001) and in the QOL scores (p < 0.001) at the end of the home-
based exercise program. The individualized home-based exercise program led to improvement in affected
upper-limb volume and circumference and QOL of postmastectomy lymphedema patients.
PMID: 22234669 [PubMed - in process]
Ann Surg. 2012 Jan 9. [Epub ahead of print]
Microvascular Breast Reconstruction and Lymph Node Transfer for Postmastectomy Lymphedema Patients.
Saaristo AM, Niemi TS, Viitanen TP, Tervala TV, Hartiala P, Suominen EA.
Source
From the Department of Plastic Surgery, Turku University Central Hospital, Turku, Finland.
Abstract
OBJECTIVE:
Postoperative lymphedema after breast cancer surgery is a challenging problem. Recently, a novel
microvascular lymph node transfer technique provided a fresh hope for patients with lymphedema. We
aimed to combine this new method with the standard breast reconstruction.
METHODS:
During 2008-2010, we performed free lower abdominal flap breast reconstruction in 87 patients. For all
patients with lymphedema symptoms (n = 9), we used a modified lower abdominal reconstruction flap
containing lymph nodes and lymphatic vessels surrounding the superficial circumflex vessel pedicle.
Operation time, donor site morbidity, and postoperative recovery between the 2 groups (lymphedema
breast reconstruction and breast reconstruction) were compared. The effect on the postoperative lymphatic
vessel function was examined.
RESULTS:
The average operation time was 426 minutes in the lymphedema breast reconstruction group and 391
minutes in the breast reconstruction group. The postoperative abdominal seroma formation was increased in
patients with lymphedema. Postoperative lymphoscintigraphy demonstrated at least some improvement in
lymphatic vessel function in 5 of 6 patients with lymphedema. The upper limb perimeter decreased in 7 of 9
patients. Physiotherapy and compression was no longer needed in 3 of 9 patients. Importantly, we found
that human lymph nodes express high levels of endogenous lymphatic vessel growth factors. Transfer of the
lymph nodes and the resulting endogenous growth factor expression may thereby induce the regrowth of
lymphatic network in the axilla. No edema problems were detected in the lymph node donor area.
CONCLUSION:
Simultaneous breast and lymphatic reconstruction is an ideal option for patients who suffer from
lymphedema after mastectomy and axillary dissection.
PMID: 22233832 [PubMed - as supplied by publisher]
Int Angiol. 2011 Dec;30(6):527-33.
Dose finding for an optimal compression pressure to reduce chronic edema of the extremities.
Partsch H, Damstra RJ, Mosti G.
Source
Private Practictioner, Vienna, Austria - hugo.partsch@meduniwien.ac.at.
Abstract
AIM:
The optimal pressure to reduce chronic extremity swelling is still a matter of debate. The aim of this paper
was to measure volume reduction of a swollen extremity depending on the amount of pressure exerted by
compression stockings and inelastic bandages.
METHODS:
Thirty-six patients with unilateral breast cancer related arm lymphedema were investigated in a lymph clinic
in the Netherlands, 42 legs with chronic edema of the lower extremities were examined in a phlebological
centre in Italy. The arm-patients were randomized to receive inelastic arm bandages with a pressure
between 20-30 mmHg or 44-68 mmHg. The leg patients were either treated with compression stockings
(23-32 mmHg) or with inelastic bandages (pressure 53-88 mmHg). Water-displacement volumetry and
measurement of leg circumference was performed before and after compression.
RESULTS:
In the arm-patients low pressure after 2 hours achieved a higher degree of volume reduction (-2.3%, 95%
CI 1.0-3.6) than high pressure (-1.5%, 95% CI 0.2-2.8) (n.s.). In patients with leg edema compression
stockings in the range between 20 and 40 mmHg showed a positive correlation between exerted pressure
and volume reduction, bandages applied with an initial resting pressure of more than 60 mm Hg resulted in a
decreasing volume reduction.
CONCLUSION:
There is obviously an upper limit beyond which further increase of compression pressure seems
counterproductive. For inelastic bandages this upper limit is around 30 Hg on the upper and around 50-60
mmHg on the lower extremity.
PMID: 22233613 [PubMed - in process]
Int Angiol. 2011 Dec;30(6):499-503.
The lymphovenous microsurgical shunts for treatment of lymphedema of lower limbs: indications in 2011.
Olszewski WL.
Source
Department of Surgical Research and Transplantology, Medical Research Center, Polish Academy of
Sciences, Warsaw, Poland - wlo@cmdik.pan.pl.
Abstract
The microsurgical lympho-venous shunts have become one of the generally accepted modalities in treatment
of limb lymphedema. This review highlight the indications for this procedure after over 40 years. This study
was based on the personal experience of one surgeon and on the review of the literature. Patients with
postinflammatory, postsurgical, idiopathic and hyperplastic lymphedema of lower limbs were included in the
study. Basing on the review of results of the last 40 years the contemporary indications are: 1) lymphedema
with local segmental obstruction but still partly patent distal lymphatics seen on functional lymphoscintigraphy
(standard walking or pneumatic compression) and without an active inflammatory process in the skin,
subcutaneous tissue and lymph vessels (DLA-dermatolymphangioadenitis); 2) classified according the
etiology of lymphedema, this operation can bring about satisfactory results in cases of hyperplastic,
postsurgical and postinflammatory types of lymphedema, whereas primary idiopathic lymphedema of non-
genetic type should be treated with conservative means, although in a small number of cases an improvement
was observed after lympho-venous shunting as long as 10 years. Microsurgical lymph node or lymphatic
vessel to vein shunts have their established position among the therapy modalities for lymphedema of lower
limbs in a strictly defined group of patients using lymphoscintigraphic imaging.
PMID: 22233610 [PubMed - in process]
J Obstet Gynaecol Res. 2012 Jan 10. doi: 10.1111/j.1447-0756.2011.01727.x. [Epub ahead of print]
Re-consideration of lymphadenectomy for stage Ib1 cervical cancer.
Kato H, Todo Y, Suzuki Y, Ohba Y, Minobe SI, Okamoto K, Yamashiro K, Sakuragi N.
Source
Divisions of Gynecologic Oncology Pathology, National Hospital Organization, Hokkaido Cancer Center,
Department of Obstetrics and Gynaecology, Hokkaido University School of Medicine, Sapporo, Japan.
Abstract
Aim: Because of less frequent lymph node metastasis and parametrial involvement, patients with stage Ib1
cervical cancer may benefit from a curtailment of surgery. We retrospectively investigated the distribution of
lymph node metastasis in stage Ib1 patients. After comparing the data with that of higher stages and sentinel
lymph node navigation (SLNN), the appropriate extent of lymphadenectomy (LA) in stage Ib1 disease was
newly suggested. Method: A total of 303 patients underwent a radical hysterectomy with LA and the
region-specific rate of node metastasis was obtained. SLNN was performed for 50 patients using (99m) Tc
phytate injection into the cervix and intra-operative detection by a gamma-probe. Results: The rate of node
metastasis and the average number of nodes removed, respectively, were: 23/189 (12.2%), 65.2 in stage
Ib1; 14/47 (29.8%), 70.1 in stage Ib2; 7/20 (35.0%), 78.2 in stage IIa; and 26/47 (55.3%), 69.1 in stage
IIb. Lymph node metastasis in stage Ib1 was prevalent in the obturator (Ob) (9.5%), inter-iliac (Ii) (4.9%),
superficial common iliac (Sc) (2.3%), cardinal (Cd) (2.2%) and external iliac (Ei) (1.7%) nodes. In patients
with upper stage disease, lymph node metastasis could occur in all lymph nodes. In stage Ib1 patients, the
sentinel nodes were assigned only to the Ob, Ii, Sc and Ei nodes, being identical with frequent metastatic
sites in stage Ib1 (excluding Cd). Conclusion: The extent of LA can be routinely completed with the
removal of Ob, Ii, Ei, Sc and Cd nodes, which may provide a higher quality of life, including the reduction of
lymphedema by preventing the removal of the inguinal nodes.
© 2012 The Authors. Journal of Obstetrics and Gynaecology Research © 2012 Japan Society of
Obstetrics and Gynecology.
PMID: 22229927 [PubMed - as supplied by publisher]
January 19, 2012
Br J Community Nurs. 2011 Oct;16 Suppl:S4-S12.
Use of compression bandaging in managing chronic oedema.
Todd M.
Abstract
Compression bandaging is a major component of most community nurses' practice in the management of
venous leg ulcers. For lymphoedema practitioners, compression therapy is the linchpin in the management of
chronic oedema and lymphoedema. There are several types of compression bandage available, with some
being part of a recognized system of compression delivery. In order for nurses to select and apply the
correct type and level of compression bandaging, there needs to be a substantial level of knowledge of the
principles of compression theory and competence in the application of bandaging. There are also issues
surrounding patient concordance, and nurses need to be able to assess and address any barriers to
concordance to ensure the most effective regimen of treatment is delivered.
PMID: 22240574 [PubMed - in process]
Br J Community Nurs. 2011 Oct;16 Suppl:S28-9.
An interview with Karen Morgan.
Morgan K.
Abstract
Karen Morgan is Lymphoedema Clinical Nurse Specialist, Abertawe Bro Morgannwg University Health
Board (ABMUHB) Lymphoedema
Health Board (ABMUHB) Lymphoedema Clinic.
PMID: 22240571 [PubMed - in process]
Br J Community Nurs. 2011 Oct;16 Suppl:S22-7.
An integrative treatment for lower limb lymphoedema in India.
Bose KS, Aggithaya GM.
Abstract
Lymphoedema is a chronic disease which requires frequent visits to therapist in developed countries. In most
developing countries, it is the disease of rural area caused by lymphatic filariasis (LF). The aim is to develop
a low cost home-based self-care protocol using the combinations of locally available treatment modalities.
The integrated treatment has the elements of therapy from modern dermatology, Ayurveda and yoga,
administered by the doctors of respective system of medicine on the basis of pathophysiological
understanding in lymphology. The sequence of treatment components that each patient followed is skin
wash, soaking the limb in herbal Phanta solution, care of bacterial entry points, a set of yoga exercises,
Indian manual lymph drainage and compression bandaging. A total of 1209 limbs in 889 patients were
treated using integrated medicine during October 2004-May 2011. All patients received an initial 14 days of
supervised treatment and training for self-care and home-based treatment to be continued for life. Patients
followed up twice. Volume reduction for large sized limbs at 3 months following treatment was 41.1%, with
a confidence interval (CI) of 5.7-6.9 litres. Reduction was 25.7 % for small limbs with a CI of 1.5-1.7 litres.
Entry points were present in 86.2% limbs at baseline and in 71.7% limbs at the end of 3 months.
Inflammatory episodes reduced from 80%-8.6%.
PMID: 22240570 [PubMed - in process]
Br J Community Nurs. 2011 Oct;16 Suppl:S20-1.
Lymphangioma or lymphangiectasia? An update for lymphoedema nurses.
Pike C.
Abstract
This article is prompted by a recent enquiry to the British Lymphology Society, expressing uncertainty over
the definition of lymphangioma. It may be prudent to publicize information on this potentially confusing area
more widely, as clinicians need to know what lymphangioma is, or is not.
PMID: 22240569 [PubMed - in process]
Br J Community Nurs. 2011 Oct;16 Suppl:S14-9.
Non-concordance in lymphorrhea of the lower limbs: a case study.
Jones J.
Abstract
Obesity and a sedentary lifestyle are fast becoming major problems for not only the NHS as a whole but
also the lymphoedema therapist. Lymphorrhea in this group of patients can be a recurrent problem, causing
strain on already stretched services and on the patient and their family. What happens when the ideas of the
patient and therapist regarding treatment are not the same? This article aims to address these issues by
looking at a case study of such a patient, and the surprising outcome that resulted when the patient got his
own way.
PMID: 22240568 [PubMed - in process]
January 22, 2012,
Br J Community Nurs. 2011 Oct;16 Suppl:S22-7.
An integrative treatment for lower limb lymphoedema in India.
Bose KS, Aggithaya GM.
Abstract
Lymphoedema is a chronic disease which requires frequent visits to therapist in developed countries. In most
developing countries, it is the disease of rural area caused by lymphatic filariasis (LF). The aim is to develop
a low cost home-based self-care protocol using the combinations of locally available treatment modalities.
The integrated treatment has the elements of therapy from modern dermatology, Ayurveda and yoga,
administered by the doctors of respective system of medicine on the basis of pathophysiological
understanding in lymphology. The sequence of treatment components that each patient followed is skin
wash, soaking the limb in herbal Phanta solution, care of bacterial entry points, a set of yoga exercises,
Indian manual lymph drainage and compression bandaging. A total of 1209 limbs in 889 patients were
treated using integrated medicine during October 2004-May 2011. All patients received an initial 14 days of
supervised treatment and training for self-care and home-based treatment to be continued for life. Patients
followed up twice. Volume reduction for large sized limbs at 3 months following treatment was 41.1%, with
a confidence interval (CI) of 5.7-6.9 litres. Reduction was 25.7 % for small limbs with a CI of 1.5-1.7 litres.
Entry points were present in 86.2% limbs at baseline and in 71.7% limbs at the end of 3 months.
Inflammatory episodes reduced from 80%-8.6%.
PMID: 22240570 [PubMed - in process]
January 22, 2012
J Cancer Surviv. 2012 Jan 13. [Epub ahead of print]
Community-based exercise program effectiveness and safety for cancer survivors.
Rajotte EJ, Yi JC, Baker KS, Gregerson L, Leiserowitz A, Syrjala KL.
Source
Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, D5-220, P.
O. Box 19024, Seattle, WA, 98109, USA.
Abstract
PURPOSE:
Clinical trials have demonstrated the benefits of exercise for cancer survivors. This investigation determined
the effectiveness and safety of a disseminated community-based exercise program for cancer survivors who
had completed treatment.
METHODS:
Personal trainers from regional YMCAs received training in cancer rehabilitation and supervised twice-a-
week, 12-week group exercise sessions for survivors. At baseline and post-program, validated measures
assessed patient-reported outcomes (PRO) and physiologic measurements.
RESULTS:
Data were collected from 221 survivors from 13 YMCA sites and 36 separate classes. All participants had
data available at one time point, while matched baseline and post-program PRO and physiologic data were
available for 85% (N = 187). Participants with matched data were largely female (82%), with mean age of
58 (range, 28-91 years). Time since diagnosis ranged from 1 to 48 (mean, 5.6 years), and mean time since
last treatment was 3.0 (range, 1-33 years). Physiological improvements were significant in systolic (P <
0.001) and diastolic (P = 0.035) blood pressure, upper and lower body strength, the 6-min walk test (P =
0.004), and flexibility (P < 0.001). Participants reported improvements in overall health-related quality of life
(P < 0.001), social support (P = 0.019), body pain (P = 0.016), fatigue (P < 0.001), insomnia (P < 0.001),
and overall musculoskeletal symptoms (P = <0.001). Few injuries or lymphedema events occurred during
classes.
CONCLUSIONS:
Community-based exercise groups for cancer survivors of mixed diagnoses and ages, who have completed
active treatment, have physiologic and psychosocial benefits, and are safe. IMPLICATIONS FOR
CANCER SURVIVORS: Survivors may expect significant benefit from participating in a community-based
exercise program tailored to meet their individual needs as a survivor.
PMID: 22246463 [PubMed - as supplied by publisher]
Hematol Oncol Clin North Am. 2012 Feb;26(1):169-94. Epub 2011 Dec 16.
Contemporary quality of life issues affecting gynecologic cancer survivors.
Carter J, Penson R, Barakat R, Wenzel L.
Source
Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
10065, USA; Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York,
NY 10065, USA.
Abstract
Regardless of cancer origin or age of onset, the disease and its treatment can produce short- and long-term
sequelae (ie, sexual dysfunction, infertility, or lymphedema) that adversely affect quality of life (QOL). This
article outlines the primary contemporary issues or concerns that may affect QOL and offers strategies to
offset or mitigate QOL disruption. These contemporary issues are identified within the domains of sexual
functioning, reproductive issues, lymphedema, and the contribution of health-related QOL in influential
gynecologic cancer clinical trials.
Copyright © 2012 Elsevier Inc. All rights reserved.
PMID: 22244668 [PubMed - in process]
MEDNEWS DOCS:
January 3, 2012
New Treatment Direction For Rare Metabolic Diseases
A research team led by biochemist Scott Garman at the University of Massachusetts Amherst has
discovered a key interaction at the heart of a promising new treatment for a rare childhood metabolic
disorder known as Fabry disease. The discovery will help understanding of other protein-folding disorders
such as Alzheimer's, Parkinson's and Huntington's diseases, as well. Findings are featured as the cover story
in the current issue of Chemistry & Biology.
People born with Fabry disease have a faulty copy of a single gene that codes for the alpha-galactosidase (α-
GAL) enzyme, one of the cell's "recycling" machines. When it performs normally, α-GAL breaks down an
oily lipid known as GB3 in the cell's recycling center, or lysosome. But when it underperforms or fails, Fabry
symptoms result. Patients may survive to adulthood, but the disorder leads to toxic lipid build-up in blood
vessels and organs that compromise kidney function or lead to heart disease, for example.
The faulty gene causes its damage by producing a misfolded protein, yielding an unstable, poorly functioning
α-GAL enzyme. Like origami papers, these proteins are unfolded to start and only become active when
folded into precise shapes. At present, enzyme replacement therapy (ERT) is the only FDA-approved
treatment for such lysosomal storage disorders as Fabry, Pompe and Gaucher diseases, but ERT requires a
complicated and expensive process to purify and replace the damaged α-GAL enzyme, and it must be
administered by a physician.
Instead of replacing the damaged enzyme, an alternative route called pharmacological chaperone (PC)
therapy is currently in Phase III clinical trials for Fabry disease. It relies on using smaller, "chaperone"
molecules to keep proteins on the right track toward proper folding, but their biochemical mechanism is not
well understood, says Garman.
Now, he and colleagues report results of a thorough exploration at the atomic level of the biochemical and
biophysical basis of two small molecules for potentially stabilizing the α-GAL enzyme. He says their use in
PC therapy could one day be far less expensive than the current standard, ERT, and can be taken orally.
This work, which improves knowledge of a whole class of molecular chaperones, represents the centerpiece
of UMass Amherst student Abigail Guce's doctoral thesis and was supported by the National Institutes of
Health. Other members of the team are graduate students Nat Clark and Jerome Rogich.
"The interactions we looked at are exactly the things occurring in the clinical trial right now," Garman says.
Further, "the same concept is now being applied to other protein-folding diseases such as Parkinson's and
Alzheimer's disease. Many medical researchers are trying to keep proteins from misfolding by using small
chaperone molecules. Our studies have definitely advanced the understanding of how to do that."
In their current paper, Garman and colleagues compare the ability of two small chaperone molecules,
galactose and 1-deoxygalactononjirimycin (DGJ) to stabilize the α-GAL protein, to help it resist unfolding in
different conditions such as high temperature and different pH levels.
They found that each chaperone has very different affinities: DGJ binds tightly and galactose binds loosely to
the α-GAL, yet they differ in only two atomic positions. "Tight is better, because you can use less drug for
treatment," Garman says. "We now can explain DGJ's high potency, its tight binding, down to individual
atoms."
In earlier studies as in the current work, the UMass Amherst team used their special expertise in X-ray
crystallography to create three-dimensional images of all atoms in the protein to understand how it carries
out its metabolic mission. They also found a new binding site for small molecules on human α-GAL that had
never been observed before.
Crystallography on the two chaperones bound to the α-GAL enzyme showed that a single interaction
between the enzyme and DGJ was responsible for DGJ's high affinity for the enzyme. Other experiments
also showed the ability of the 11- and 12-atom chaperones to protect the large, 6,600-atom α-GAL from
unfolding and degradation.
For the first time, by making a single change in one amino acid in protein, they forced the DGJ to bind
weakly, indicating that one atomic interaction is responsible for DGJ's high affinity.
"It was surprising to find these two small molecules that look very much the same have very different
affinities for this enzyme," says Garman, "and we now understand why. The iminosugar DGJ has high
potency due to a single ionic interaction with α-GAL. Overall, our studies show that this small molecule
keeps the enzyme from unfolding, or when it unfolds, the process happens more slowly, all of which you
need in treating disease."
The UMass Amherst team plans to next use the principles, assays and experiments they developed here on
enzymes defective in other human diseases to examine new therapies for them and related disorders.
JANUARY 9, 2012
Significant Cost Savings Associated With Emergence Of Prospective Surveillance Model As Standard Of
Care For Breast Cancer Treatment
Early diagnosis and treatment of breast cancer-related lymphedema by a physical therapist can significantly
reduce costs and the need for intensive rehabilitation, according to an article published in the January issue of
Physical Therapy (PTJ), the scientific journal of the American Physical Therapy Association (APTA).
The study, led by APTA member and spokesperson Nicole Stout, PT, MPT, CLT-LANA, compared a
prospective surveillance model with a traditional model of impairment-based care and examined the direct
treatment costs associated with each program. Treatment and supply costs were estimated based on the
Medicare 2009 physician fee schedule. Researchers estimated that treatment for breast cancer-related
lymphedema costs $636.19 a year when the prospective surveillance model was used vs $3,124.92 for
traditional treatment of advanced lymphedema.
The goal of a prospective surveillance model for cancer rehabilitation is to identify impairment at the earliest
onset to alleviate impairment or prevent it from progressing. Soon after diagnosis, a physical therapist will
perform a preoperative examination to establish a baseline level of function. Follow-up examinations are then
conducted postoperatively at 1 month and then 3-month intervals, for up to 1 year. In contrast, a traditional
model focuses on treating lymphedema once it has progressed and patients already have functional
limitations.
"This study begins to paint a picture of evidence showing that prevention of chronic conditions such as
lymphedema - using rehabilitation models of care - may result in significant cost savings," said Stout.
Breast cancer-related lymphedema is characterized by abnormal swelling of the arm and hand, which can be
disfiguring. A chronic condition, it is associated with decreased arm function, disability, and diminished
quality of life. If the condition is not diagnosed early and managed, a patient can be at risk for infection and
further shoulder complications.
In place for more than 10 years, the prospective surveillance model was developed at the National Naval
Medical Center in Bethesda - now part of the Walter Reed National Military Medical Center - and is the
standard of care for all patients diagnosed with breast cancer at the medical center. Several research articles
have been published demonstrating clinical effectiveness of the prospective surveillance model in reducing
lymphedema, shoulder morbidity, and fatigue, including the February 2010 article in the journal Breast
Cancer Research and Treatment.
Although further analysis of indirect costs and utility is necessary to fully assess cost effectiveness, the
prospective surveillance model is emerging as the standard of care for breast cancer treatment.
January 15, 2012
New, Noninvasive Way To Identify Lymph Node Metastasis
Using two cell surface markers found to be highly expressed in breast cancer lymph node metastases,
researchers at Moffitt Cancer Center, working with colleagues at other institutions, have developed targeted,
fluorescent molecular imaging probes that can non-invasively detect breast cancer lymph node metastases.
The new procedure could spare breast cancer patients invasive and unreliable sentinel lymph node (SLN)
biopsies and surgery-associated negative side effects.
Their study was published in a recent issue of Clinical Cancer Research (18:1), a publication of the
American Association for Cancer Research.
"The majority of breast cancer patients, up to 74 percent, who undergo SLN biopsy are found to be
negative for axillary nodal, or ALN, metastases," said corresponding author David L. Morse, Ph.D., an
associate member at Moffitt whose research areas include experimental therapeutics and diagnostic imaging.
"Determining the presence or absence of ALN metastasis is critical to breast cancer staging and prognosis.
Because of the unreliability of the SLN biopsy and its potential for adverse effects, a noninvasive, more
accurate method to assess lymph node involvement is needed."
The authors note that the postoperative complications to the SLN biopsy can include lymphedema, seroma
formation, sensory nerve injury and limitations in patient range of motion. In addition, biopsies fail to identify
disease in axillary lymph nodes in five to 10 percent of patients.
In developing targeted molecular probes to identify breast cancer in axillary lymph nodes, the research team
from Moffitt, the University of Arizona and University of Florida used two surface cell markers - CAIX and
CAXII. CAIX is a cell surface marker known to be "highly and broadly expressed in breast cancer lymph
node metastases" and absent in normal tissues.
CAIX and CAXII are both integral plasma membrane proteins with large extracellular components that are
accessible for binding of targeted imaging probes, explained Morse. In addition, several studies have shown
that CAIX expression is associated with negative prognosis and resistance to chemo and radiation therapy
for breast cancer. CAXII is a protein expressed in over 75 percent of axillary lymph node metastases.
The researchers subsequently developed their targeting agents by using monoclonal antibodies specific for
binding CAIX and CAXII, both of which are known to promote tumor growth.
According to the researchers, a number of noninvasive optical imaging procedures for SLN evaluation have
been investigated, but the approaches have lacked the ability to target tumor metastasis biomarkers.
"These methods provide only anatomic maps and do not detect tumor cells present in lymph nodes,"
explained Morse. "Using mouse models of breast cancer metastasis and a novel, monoclonal anti-body-
based molecular imaging agents, we developed a targeted, noninvasive method to detect ALN metastasis
using fluorescence imaging."
In addition to the imaging study with mice, the researchers also reported that the combination of CAIX and
CAXII covered 100 percent of patient-donated samples used in their tissue microarray (TMA) study.
"The imaging probes detected tumor cells in ALNs with high sensitivity," explained Morse. "Either CAIX or
CAXII were expressed in 100 percent of the breast cancer lymph node metasatsis samples we surveyed in
this study. These imaging probes have potential for providing a noninvasive way to stage breast cancer in the
clinic without unneeded and costly surgery."