| LYMPHLAND |
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| MARCH 2008 LYMPHEDEMA ABSTRASTS |
| Blood. 2008 Mar 1;111(5):2657-66. Epub 2007 Dec 19.
Sox18 and Sox7 play redundant roles in vascular development.Cermenati S, Moleri S, Cimbro S, Corti P, Del Giacco L, Amodeo R, Dejana E, Koopman P, Cotelli F, Beltrame M. Mutations in SOX18 cause the human hypotrichosis-lymphedema-telangiectasia (HLT) syndrome. Their murine counterparts are the spontaneous ragged mutants, showing combined defects in hair follicle, blood vessel, and lymphatic vessel development. Mice null for Sox18 display only mild coat defects, suggesting a dominant-negative effect of Sox18/ragged mutations and functional redundancy between Sox18 and other Sox-F proteins. We addressed this point in zebrafish. The zebrafish homologs of Sox18 and of Sox7 are expressed in angioblasts and in the endothelial component of nascent blood vessels in embryos. Knockdown of either gene, using moderate doses of specific morpholinos, had minimal effects on vessels. In contrast, simultaneous knockdown of both genes resulted in multiple fusions between the major axial vessels. With combined use of transgenic lines and molecular markers, we could show that endothelial cells are specified, but fail to acquire a correct arteriovenous identity. Venous endothelial cell differentiation was more severely affected than arterial. Thus, sox7 and sox18 play redundant but collectively essential roles in the establishment of proper arteriovenous identity in zebrafish. Our data suggest that a defect in arteriovenous identity could be responsible for the formation of telangiectases in patients with HLT. PMID: 18094332 [PubMed - in process] ------------------------- Clin Nucl Med. 2008 Mar;33(3):226-7. Usefulness of lymphoscintigraphy in demonstrating lymphedema in patients with noonan syndrome.Cheng MF, Wu YW, Tzen KY, Yen RF. From the Department of Nuclear Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan. Lymphatic dysplasia/hypoplasia is found in 15% to 20% of patients with Noonan syndrome. We report a 16-year-old boy with a classic phenotype of Noonan syndrome but a normal karyotype in chromosomal study. During the last 5 years, he had progressive bilateral lower limb edema. The microfilaria study, duplex sonography, and MRI of the lower extremities were all unremarkable. But lymphoscintigraphy showed stocking-like dermal backflow in both legs, delayed lymphatic flow to the inguinal nodes, and dilated lymphatic channels in the abdomen and thorax. These findings suggest that lymphoscintigraphy may be useful in providing vital information on the lymphatic drainage for patients with Noonan syndrome. PMID: 18287856 [PubMed - in process] ----------------------------------------------------- Clin Nucl Med. 2008 Mar;33(3):175-180. FDG-PET on the Trail of an Unsuspected Primary Malignancy in the Breast.Dockery KF, Puri S, Qazi R, Davis D. From the **Department of Imaging Sciences, University of Rochester Medical Center; and ††Division of Hematology-Oncology, University of Rochester Medical Center, Highland Hospital, Rochester, New York. Proper identification of the primary malignancy can radically alter clinical management for the patient's benefit. This is a report of an unsuspected primary breast cancer in a patient being worked up for presumptive lymphoma. Prior investigation of lymphedema in the left lower extremity found widespread lymphadenopathy on computed tomography imaging, leading to initial biopsy revealing adenocarcinoma of unknown primary. F-18 fluorodeoxyglucose PET/computed tomography altered management by localizing an F-18 fluorodeoxyglucose avid breast nodule, directing breast biopsy with specific immunohistochemical analysis for breast cancer lineage in metastatic adenocarcinoma. The patient responded well to breast cancer-targeted chemotherapy. PMID: 18287839 [PubMed - as supplied by publisher] ------------------------------------------------------ Eur J Hum Genet. 2008 Mar;16(3):300-4. Epub 2008 Jan 16. Primary non-syndromic lymphoedema (Meige disease) is not caused by mutations in FOXC2.Rezaie T, Ghoroghchian R, Bell R, Brice G, Hasan A, Burnand K, Vernon S, Mansour S, Mortimer P, Jeffery S, Child A, Sarfarazi M. 1Molecular Ophthalmic Genetics Laboratory, Department of Surgery, University of Connecticut Health Center, Farmington, CT, USA. Primary lymphoedema is a genetic disorder with numerous phenotypic subgroups. The most common form is the non-syndromic Meige disease, which is primarily of pubertal or later onset, with oedema clinically indistinguishable from that found in the lymphoedema-distichiasis syndrome. There are also other very rare forms of lymphoedema such as yellow nail syndrome and lymphoedema with ptosis, which are clinically similar to Meige disease. The only causative genes so far identified for the non-congenital primary lymphoedemas are the transcription factor FOXC2, where mutations are known to produce lymphoedema with distichiasis, and SOX18 in the very rare condition hypotrichosis-lymphoedema-telangiectasia. This study has examined FOXC2 gene by sequence analysis in 23 affected individuals with Meige disease. A novel truncating mutation (c.563-584del) was identified in one family and found to segregate with the disease in eight affected relatives over three generations. This deletion creates a frameshift that predicts a premature stop at nucleotide 599 and truncating the normal protein by 38%. Although the affected patient initially selected for mutation screening from this family had lymphoedema without distichiasis, all but one of his affected relatives who carried the FOXC2 mutation did have accessory eyelashes originating from their meibomian glands. This is further confirmation that of the primary lymphoedemas, only lymphoedema with distichiasis is caused by FOXC2 mutations. All forms of post-pubertal lymphoedema need careful phenotyping for distichiasis, which may prove difficult to confirm unless several family members are examined, and cannot ever be assumed to be absent from self-report.European Journal of Human Genetics (2008) 16, 300-304; doi:10.1038/sj.ejhg.5201982; published online 16 January 2008. PMID: 18197197 [PubMed - in process] -------------------------------------------------------------- Hum Genet. 2008 Mar;123(2):197-205. Epub 2008 Jan 10. Congenital, low penetrance lymphedema of lower limbs maps to chromosome 6q16.2-q22.1 in an inbred Pakistani family.Malik S, Grzeschik KH. Zentrum für Humangenetik, Philipps-Universität Marburg, Bahnhofstr. 7, 35037, Marburg, Germany, malik@staff.uni-marburg.de. Hereditary lymphedema is a rare, lymphatic disorder resulting in the chronic swelling of the extremities. It shows wide inter- and intra-familial clinical heterogeneity as well as variability in the age of onset. There are more than four genetically distinct lymphedema conditions known and mutations in three genes have been discovered in families with lymphedema. However, many other familial lymphedemas do not show linkage with the known loci, suggesting genetic heterogeneity. Here, we describe a large inbred Pakistani family with congenital, progressive lymphedema confined to the lower limbs, which fades away at 40-45 years of age. This condition segregates in an autosomal dominant fashion with reduced penetrance. The features are close to primary lymphedema I, Nonne-Milory type (MIM 153100). We exclude this condition for linkage to the known loci for lymphedema by employing highly polymorphic microsatellite markers from these intervals. Then, through a genome-wide linkage study we show that the malformation in our family maps to chromosome 6q16.2-q22.1. The highest pair-wise LOD score (Z (max) = 3.19) was obtained with microsatellite marker D6S1671, and a multipoint score of 3.75 was obtained at 108 cM. Haplotype analysis indicated that the critical interval in this family flanks between markers D6S1716 and D6S303. Mutation analysis in FOXO3, a likely candidate within this interval, did not show any pathogenic change in the affected family subjects. Our study provides an evidence of a second locus for lymphedema type I. The discovery of the underlying gene could be helpful for the understanding of this heterogeneous hereditary condition. PMID: 18193458 [PubMed - in process] --------------------------------------------------------------- Nat Clin Pract Endocrinol Metab. 2008 Mar;4(3):173-7. Epub 2008 Jan 29. Hormonal therapy in a patient with a delayed diagnosis of Turner's syndrome.Gawlik A, Malecka-Tendera E; Vanderbilt. Department of Pediatric Endocrinology and Diabetes of the Medical University of Silesia, Katowice, Poland. BACKGROUND: A 15-year-old girl presented to our clinic with short stature and delayed puberty. On examination her height was 139.3 cm, which is 13.2 cm below the 3(rd) percentile on a standard growth chart, and she had no clinical signs of puberty. A number of typical features of Turner's syndrome were found, including a short webbed neck, cubitus valgus, shield chest, multiple pigmented nevi, lymphedema, epicanthus and micrognathia. INVESTIGATIONS: Plasma follicle-stimulating hormone and luteinizing hormone levels were increased. A pelvic ultrasound demonstrated a small uterus, but the ovaries could not be visualized. The patient's bone age was 12-13 years. A horseshoe kidney was seen on renal ultrasound and an echocardiography revealed aortic coarctation. The 45,X karyotype confirmed the diagnosis. DIAGNOSIS: Turner's syndrome. MANAGEMENT: Growth hormone therapy (1 IU/kg/week; approximately 0.05 mg/kg/day) was started together with oxandrolone (0.05 mg/kg/day) and transdermal estrogen. The dose of estrogen was gradually increased from 12.5 microg/day to 25.0 microg/day and then to 50.0 microg/day over a period of 12 months. Growth hormone and oxandrolone were withdrawn after 1 year, when the patient's epiphyses had fused. Hormonal replacement therapy with estrogens was continued and the patient has reached stage 3 of pubertal development and a final height of 148.5 cm. PMID: 18227816 [PubMed - in process] ******************************************************************************************** J Am Acad Dermatol. 2008 Feb 27 Acute dermal abscesses caused by Serratia marcescens. Soria X, Bielsa I, Ribera M, Herrero MJ, Domingo H, Carrascosa JM, Ferrándiz C. Department of Dermatology, Hospital Universitari Arnau de Vilanova, Universitat de Lleida, Lleida, Spain. Primary acute cutaneous infections caused by Serratia marcescens are extremely unusual. Nevertheless, Serratia infections are especially frequent in chronic granulomatous disease, which is a primary immunodeficiency that affects phagocytic cells of the innate immune system. We report a young man without history of infections, who developed multiple dermal abscesses on a leg with chronic lymphoedema attributed to S marcescens. Laboratory investigations showed a delayed partial neutrophilic oxidative function. It is remarkable that the patient did not have any other infections during childhood, when most of the innate immune deficiencies are diagnosed, and he had no history of granulomatous lesions. We hypothesize that the delayed neutrophilic oxidative function could be explained by a partial neutrophilic oxidative function, which could be enough to maintain the patient asymptomatic until this infection. PMID: 18313173 [PubMed - as supplied by publisher] ********************************************************************************** Psychooncology. 2008 Mar 3 Applying a conceptual model for examining health-related quality of life in long-term breast cancer survivors: CALGB study 79804. Paskett ED, Herndon JE 2nd, Day JM, Stark NN, Winer EP, Grubbs SS, Pavy MD, Shapiro CL, List MA, Hensley ML, Naughton MA, Kornblith AB, Habin KR, Fleming GF, Bittoni MA; for the Cancer and Leukemia Group B. The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA. Objectives: The Survivor's Health and Reaction study used a quality-of-life model adapted for cancer survivors by Dow and colleagues to identify factors related to global health-related quality of life (HRQL) and to document the prevalence of problems and health-oriented behaviors in a follow-up study of breast cancer patients who participated in CALGB 8541.Methods: A total of 245 survivors (78% of those invited) who were 9.4-16.5 years post-diagnosis completed surveys that inquired about current HRQL, economic, spiritual, physical and psychosocial concerns, and health-oriented behaviors (e.g. smoking, exercise, and supplement use). A regression model was developed to examine factors related to global HRQL across all domains.Results: The regression model revealed that decreased energy levels (odds ratio (OR)=1.05, 95% confidence interval (CI): 1.03, 1.07), having heart disease (OR=5.01, 95% CI: 1.39, 18.1), having two or more co-morbidities (OR=2.39, 95% CI: 1.10, 5.19), and lower social support (OR=1.03, 95% CI: 1.02, 1.05) were associated with lower global HRQL. Factors related to psychological, spiritual, and economic domains were not predictive of global HRQL. Regarding lifestyle changes, some women reported engaging in health-oriented behaviors since their cancer diagnosis, such as improving eating habits (54%), increasing exercise (32%), and reducing/quitting smoking (20%). The most prevalent problems reported by women at follow-up were menopausal symptoms (64%), such as hot flashes and vaginal dryness, osteoporosis (25%), and lymphedema (23%).Conclusion: Suggestions are provided to target interventions, such as provider-based strategies, in order to improve HRQL in long-term breast cancer survivors. Copyright (c) 2008 John Wiley & Sons, Ltd. PMID: 18314912 [PubMed - as supplied by publisher] ********************************************************************************** Angiology. 2008 Feb-Mar;59(1):77-83. Lymphatic Tissue Transplant in Lymphedema--A Minimally Invasive, Outpatient, Surgical Method: A 10-Year Follow-up Pilot Study. Belcaro G, Errichi BM, Cesarone MR, Ippolito E, Dugall M, Ledda A, Ricci A. Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy. Cardres@abol.it. Lymphedema is mainly characterized by swelling, fibrosis, and nonpitting edema. The aim of this study was evaluation of the long-term (10 years) effects of autologus lymphatic tissue implant in lymphedema. Lymphatic tissue from 9 patients (harvested form the same patient in areas not affected by lymphedema) was reimplanted into the affected limb, and these patients were followed for 10 years. Lymph nodes were harvested at the neck, axillary, or inguinal space (contralateral limb). Results showed that limb volume was decreased in the treatment group vs. controls. In ultrasound, black, low density, lymphatic spaces were visible in 100% of patients at inclusion but in only 23% of these subjects at 10 years. Thus, this early report proposes a new, minimally invasive method to improve lymphedema. Studies in progress will indicate the role of lymphatic transplant in the management of lymphedema and the best indications for this method. PMID: 18319226 [PubMed - in process] ****************************************************************************************** Dermatol Online J. 2008 Jan 15;14(1):1. Pattern of non-venereal dermatoses of female external genitalia in South India. Singh N, Thappa DM, Jaisankar TJ, Habeebullah S. Department of Dermatology and Sexually Transmitted Diseases, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India. Non-venereal dermatoses tend to be confused with venereal diseases, which may be responsible for mental distress and guilt feelings in patients. We conducted the study to find the pattern of non-venereal dermatoses of female external genitalia and to correlate non-venereal dermatoses with various clinical parameters. The study included 120 female patients with non-venereal dermatoses of female external genitalia presenting over a period of 22 months from September 2005 to June 2007. The demographic characteristics and clinical findings were recorded. Cases having venereal diseases were excluded from the study. A total of nineteen non-venereal dermatoses were noted in the study. The most common non-venereal dermatoses were lichen sclerosus (26 cases or 21.7%), vitiligo (19 cases or 15.8%), lichen simplex chronicus (16 cases or 13.3%), and vulval candidiasis (11 or 9.2%). Other dermatoses included lymphedema, invasive squamous cell carcinoma, tinea cruris, psoriasis, furuncle, folliculitis, lichen planus, epidermal inclusion cyst, herpes zoster, irritant contact dermatitis, acrochordon, Bartholin cyst, fibroepithelial stromal polyp, molluscum contagiosum (autoinoculated), and streptococcal vulvitis. This study highlights the importance of diagnosing non-venereal dermatoses and refutes the general misconception that all vulval itching is the result of fungal infection. The two most common causes of vulval itching observed in the study were lichen sclerosus and lichen simplex chronicus. PMID: 18319018 [PubMed - in process] ****************************************************************************** Nurs Stand. 2008 Feb 20-26;22(24):53-4, 56, 58 passim. Non-cancer-related lymphoedema of the lower limb. Keen DC. Carmarthenshire NHS Trust. delia.keen@carmarthen.wales.nhs.uk Lymphoedema is an incurable, progressive condition causing pain, psychological distress and mobility difficulties. Excessive swelling, worsening skin breakdown and leakage of lymph adversely affect the patient's quality of life while also placing increasing demands on district nursing resources. This article reviews the prevalence of non-cancer-related lower limb lymphoedema, the patient experience, management of the condition and district nurses' knowledge in this area. PMID: 18318320 [PubMed - in process] ********************************************************************************** Plast Reconstr Surg. 2008 Mar;121(3):150e-152e.Related Articles, Links Microvascular transfer of a "lymphatic-bearing" flap in the treatment of obstructive lymphedema. Li S, Cao W, Cheng K, Chang TS. Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Medical School of Shanghai Jiao Tong University, Shanghai, PR China. microsurgery_9@yahoo.com.cn PMID: 18317115 [PubMed - in process] ************************************************************************************** Curr Opin Infect Dis. 2008 Apr;21(2):122-8. Management of common bacterial infections of the skin. Bernard P. Department of Dermatology, Robert Debré Hospital, Reims, France. PURPOSE OF REVIEW: Bacterial skin infections commonly encountered in the community include impetigo, folliculitis/furunculosis, simple abscesses, erysipelas and other nonnecrotizing cellulitis. The review focuses on recent epidemiological, bacteriological and therapeutic advances. RECENT FINDINGS: Impetigo and erysipelas occur in about 20 and 1 person/1000/year, respectively. Main risk factors for erysipelas are toe-web intertrigo and lymphedema. The true incidence of furunculosis is unknown, whereas outbreaks in small communities are reported worldwide. Staphylococcus aureus is the predominant pathogen for impetigo and furunculosis, and methicillin-resistant strains play a growing role in both diseases. Erysipelas are mainly caused by streptococci, whereas local complications (i.e. abscesses or blisters) may be due to staphylococci, including methicillin-resistant strains in involved geographic areas. Recent trends for treating impetigo and furunculosis predate community-acquired methicillin-resistant S. aureus. For outbreaks of furunculosis, stringent decolonization measures are showing promise, whereas there is no validated therapeutic regimen for chronic furunculosis. Current trends for erysipelas involve ambulatory treatments and reduced duration of antibiotics. SUMMARY: Despite better epidemiological or bacteriological knowledge of common bacterial skin infections, the exact role of methicillin-resistant staphylococci needs regular surveys in involved geographic areas. Antibiotic treatment must be active on staphylococci and, to a lesser degree, on streptococci. PMID: 18317033 [PubMed - in process] |
| AIDS Read. 2008 Feb;18(2):81-2. Images in HIV/AIDS. Elephantiasis nostras verrucosa secondary to Kaposi sarcoma: a rare case. Sathyakumar S, Suh JS, Sharp VL, Polsky B. Division of Infectious Disease, St. Luke's-Roosevelt Hospital Center, New York, USA. Publication Types: Case Reports PMID: 18330034 [PubMed - indexed for MEDLINE] Acta Gastroenterol Belg. 2007 Oct-Dec;70(4):357-9. One-sided limb lymphedema in a liver transplant recipient receiving sirolimus. van Onna M, Geerts A, Van Vlierberghe H, Berrevoet F, de Hemptinne B, Troisi R, Colle I. Department of Gastroenterology and Hepatology, Ghent University Hospital, Belgium. Sirolimus (SRL) is associated with many side effects including hypercholesterolemia, anaemia, impaired wound healing and abnormal liver function tests. Limb lymphedema has only been reported several times in renal transplant recipients. We present a case of lower limb lymphedema that occurred in a 59-year-old liver transplant recipient after being on a SRL regimen for seven months. Extensive diagnostic investigations could not reveal signs of infection, venous obstruction or malignancy. After discontinuation of SRL, the lymphedema gradually resolved during the next three months. The pathologic mechanism behind this phenomenon is unknown, but antiangiogenetic and antiproliferative properties of SRL have been hold responsible. Further studies are necessary to explain this rare side effect. PMID: 18330092 [PubMed - in process] |
| BJU Int. 2008 Mar 4 [Epub ahead of print]Related Articles, Links
The management of genital lymphoedema. Garaffa G, Christopher N, Ralph DJ. St Peter’s Department of Andrology, and The Institute of Urology, London, UK. OBJECTIVES To report our experience and management of genital lymphoedema, as this condition can be extremely debilitating and difficult to manage. PATIENTS AND METHODS The clinical records of 90 patients with genital lymphoedema who presented between 1998 and 2007 were retrospectively reviewed. The surgical management of 34 patients consisted of the excision of the affected skin and of the subcutaneous layers. This involved scrotal excision in 15 patients with primary closure. Skin grafts were required in seven patients for penile shaft cover. The results for cosmesis, recovery of sexual function, patient's satisfaction and complications are discussed. RESULTS In all, 56 patients were successfully managed conservatively by treating the underlying condition, antibiotic administration, compression and elevation of the genitalia. The remaining 34 patients required surgical management with an overall excellent cosmetic result and a significant improvement in sexual function. CONCLUSIONS When surgery is necessary for genital lymphoedema, the new techniques described provide excellent cosmetic and functional results. PMID: 18325055 [PubMed - as supplied by publisher] http://www.ncbi.nlm.nih.gov/pubmed/18325055?dopt=Abstract |
| Ann Dermatol Venereol. 2008 Feb;135(2):123-126. Epub 2008 Feb 1.
[Disseminated cutaneous leishmaniasis secondary to lymphoedema: Two cases.] [Article in French] Meziou TJ, Chaabčne H, Masmoudi A, Boudaya S, Cheikhrouhou H, Bouassida S, Turki H. Service de dermatologie, EPS Hédi Chaker, Sfax 3029, Tunisie. BACKGROUND: Dissemination of cutaneous leishmaniasis may take various forms: satellite papules, sporotrichoid nodules and widespread papulonodular lesions (disseminated cutaneous leishmaniasis). We describe a particular clinical form of dissemination in two patients with erysipelas secondary to lymphoedema. PATIENTS AND METHODS: Case 1. A 75-year-old man with diabetes consulted for erysipelas of the leg secondary to lymphoedema. The site of entry was an infected cutaneous leishmaniasis lesion. The initial outcome was favourable under intravenous penicillin G treatment. Twelve days later, some fifty papulonodular lesions appeared and were strictly limited to the erythematous erysipelas plaque. PCR screening of papulonodular lesion smears for Leishman bodies was positive. Histological examination of skin biopsy samples showed lobular panniculitis. Case 2. A 64-year-old woman with diabetes presented erysipelas in the right upper limb secondary to lymphoedema scattered with multiple erythematous, infiltrated, papular lesions in a setting of cutaneous leishmaniasis lesions. PCR analysis of smears taken from the secondary nodular lesions demonstrated the presence of leishmaniasis, while histological analysis of biopsy samples revealed panniculitis. DISCUSSION: Disseminated cutaneous leishmaniasis is characterized by the appearance of multiple (>10) pleomorphic lesions on two or more noncontiguous areas of the body. Our two patients presented certain features of disseminated cutaneous leishmaniasis. However, they were unusual in terms of the strict localisation of nodular lesions to the erysipelas plaque. This particular aspect suggests haemolymphatic dissemination of the protozoan infection from the initial lesion as a result of local factors. PMID: 18342094 [PubMed - as supplied by publisher]http://www.ncbi.nlm.nih.gov/pubmed/18342094?dopt=Abstract ============================================================================================ Urology. 2008 Mar 14 [Epub ahead of print] Modern Management of Adult-Acquired Buried Penis. Tang SH, Kamat D, Santucci RA. Department of Urology, Tri-Service General Hospital, Taipei, Taiwan. OBJECTIVES: To report our successful experience in managing acquired adult buried penis from nontraumatic origins. We describe a combination of modern techniques involving escutcheonectomy, scrotoplasty, split-thickness skin graft, and fibrin sealant application for genital reconstruction. METHODS: From 2004 through 2007, 5 men with acquired adult buried penis underwent surgical repair at our medical center, by a single surgeon. A buried penis was a result of obesity in 4 of 5 patients, although other complicating factors, such as scrotal lymphedema, lichen sclerosis, and peripenile woody induration, were present in 3 of the 5 patients. All 5 patients required scrotoplasty and split-thickness skin grafts fastened with dilute fibrin glue to cover the penile skin defects. Excision of the excessive suprapubic fat pad (escutcheonectomy) was performed in the 4 obese patients. RESULTS: All patients achieved excellent cosmetic results, with successful and lasting unburying achieved in all cases. The operative difficulty, intraoperative blood loss, and length of hospital stay varied. No wound complications developed at the skin donor sites, and a rate of 80% to 100% graft take was observed on the penis at 2 months postoperatively. Abdominal wound complications were noted in 2 patients and resolved with daily dressing changes. CONCLUSIONS: Acquired adult buried penis is a correctable problem. The use of combined techniques, including surgical unburying, scrotoplasty, escutcheonectomy, and split-thickness skin grafts fixed with dilute fibrin glue, appears to be a useful approach to repair this unique condition. PMID: 18343486 [PubMed - as supplied by publisher] http://www.ncbi.nlm.nih.gov/pubmed/18343486?dopt=Abstract ++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ Trop Med Int Health. 2008 Mar 12 [Epub ahead of print]Related Impact of seven rounds of mass administration of diethylcarbamazine and ivermectin on prevalence of chronic lymphatic filariasis in south India. Yuvaraj J, Pani SP, Vanamail P, Ramaiah KD, Das PK. Vector Control Research Centre, Pondicherry, India. Objective To evaluate the impact of seven rounds of mass administration of diethylcarbamazine (DEC) and ivermectin on the prevalence of chronic lymphatic filariasis and to compare it with that observed in a placebo arm in a community-level trial. Methods Cross-sectional clinical surveys were carried out before and after seven rounds of mass drug administration (MDA). About 54-75% of the target population were treated at each round of MDA. Results After seven rounds, the hydrocele prevalence had declined from the pre-intervention level of 20.5-5.1% (P < 0.05) in the DEC arm, from 23.9% to 10.4% (P < 0.05) in the ivermectin arm and from 20.4% to 10.9% (P < 0.05) in the placebo arm, equivalent to reductions of 75.3%, 56.6% and 46.6%, respectively. The lymphoedema/elephantiasis prevalence declined only marginally and without statistical significance from 3.7% to 3.2%, 4.6% to 3.9% and 2.9% to 2.3% in the DEC, ivermectin and placebo arm. After the seventh MDA, none of the sampled people in the 0-20 age group was found with hydrocele and there was a statistically significant decline in hydrocele prevalence in all other age groups in the communities treated with DEC, the drug known to have macrofilaricidal effect. The impact was relatively less in ivermectin arm. Conclusion Repeated DEC administration has the potential to prevent incidence of new hydrocele cases and may resolve the manifestation at least in a proportion of affected people. Apart from reducing the microfilaraemia prevalence and transmission of infection, MDA also results in significant public health benefits by reducing the burden of hydrocele in treated communities. PMID: 18346027 [PubMed - as supplied by publisher] http://www.ncbi.nlm.nih.gov/pubmed/18346027?dopt=Abstract +++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ Arch Dermatol. 2008 Mar;144(3):366-72. A human papillomavirus-associated disease with disseminated warts, depressed cell-mediated immunity, primary lymphedema, and anogenital dysplasia: WILD syndrome. Kreuter A, Hochdorfer B, Brockmeyer NH, Altmeyer P, Pfister H, Wieland U; Competence Network HIV/AIDS. Department of Dermatology and Allergology, Ruhr-University Bochum, Gudrunstrasse 56, D-44791 Bochum, Germany. a.kreuter@derma.de BACKGROUND: Epidermodysplasia verruciformis (EV) is a rare genodermatosis associated with infections with specific human papillomaviruses (HPVs) belonging to the beta genus of HPV. Patients with EV usually have a selective defect in cell-mediated immunity. Although skin cancer frequently develops in the sun-exposed cutaneous lesions of patients with EV, the anogenital area is usually not affected by squamous cell carcinomas related to mucosal HPV types. OBSERVATIONS: We report the case of a patient with clinical similarities to EV who also presented with primary lymphedema, anogenital dysplasias, and depressed cell-mediated immunity. Swab samples and biopsy specimens from various body sites collected over a 28-month period were screened by different protocols for DNA of the HPV groups alpha, beta, and mu/nu. Seventeen alpha-HPV types could be demonstrated. Interestingly, beta-HPVs (HPV-22 and HPV-23) were detectable only in plucked eyebrows and in 1 skin swab sample. None of the specimens from lesional biopsies carried beta-HPV. Consistently found alpha-HPV types included HPV types 6, 51, 52, 61, and 84 in the genitoanal region and HPV-57 in skin lesions. Histological and cytological evaluation revealed multifocal anogenital dysplasia and benign genital and cutaneous warts. CONCLUSIONS: To our knowledge, only 1 other similar case of an EV-like syndrome with impaired, cell-mediated immunity and primary lymphedema has been described in the literature. Based on the characteristic clinical and virological findings in the present case and the previously published case, we speculate that both patients could have a previously unknown syndrome that has clinical similarities to EV but notably differs in the associated HPV types. We suggest the acronym WILD (warts, immunodeficiency, lymphedema, dysplasia) to characterize this syndrome. Publication Types: Research Support, Non-U.S. Gov't PMID: 18347293 [PubMed - in process] http://www.ncbi.nlm.nih.gov/pubmed/18347293?dopt=Abstract |
| abstracts
http://www.ncbi.nlm.nih.gov/pubmed/18361264?dopt=Abstract Phlebology. 2008;23(1):10-4. Is there a risk for lymphatic complications after endovenous laser treatment versus cryostripping of the great saphenous vein? A prospective study. Disselhoff BC, der Kinderen DJ, Moll FL. Department of Surgery, Mesos Medical Centre, Utrecht, The Netherlands. bcvmdisselhoff@mesos.nl OBJECTIVE: To investigate whether lymphatic complications occur after endovenous laser treatment (EVLT) versus cryostripping. METHODS: A prospective analysis of patients who underwent lymphoscintigraphy before and six months after treatment of primary varicose veins. RESULTS: Of 120 patients randomized in a clinical trial comparing EVLT and cryostripping, 33 agreed to participate in this study. Six months after treatment, none of the 17 patients treated with EVLT and one (6.3%) of the 16 patients treated with cryostripping had clinical grade 1 lymphoedema, with marked disruption of the lymphatics around the knee. This patient also showed an abnormal uptake of radioactive tracer at the groin, 120 min after injection. CONCLUSION: This study demonstrated that no lymphatic complications occurred six months after EVLT, whereas one lymphatic complication occurred after cryostripping, however not in the groin but at the knee. PMID: 18361264 [PubMed - in process] |
| Phlebology. 2008;23(1):10-4.Related Articles, Links
Is there a risk for lymphatic complications after endovenous laser treatment versus cryostripping of the great saphenous vein? A prospective study. Disselhoff BC, der Kinderen DJ, Moll FL. Department of Surgery, Mesos Medical Centre, Utrecht, The Netherlands. bcvmdisselhoff@mesos.nl OBJECTIVE: To investigate whether lymphatic complications occur after endovenous laser treatment (EVLT) versus cryostripping. METHODS: A prospective analysis of patients who underwent lymphoscintigraphy before and six months after treatment of primary varicose veins. RESULTS: Of 120 patients randomized in a clinical trial comparing EVLT and cryostripping, 33 agreed to participate in this study. Six months after treatment, none of the 17 patients treated with EVLT and one (6.3%) of the 16 patients treated with cryostripping had clinical grade 1 lymphoedema, with marked disruption of the lymphatics around the knee. This patient also showed an abnormal uptake of radioactive tracer at the groin, 120 min after injection. CONCLUSION: This study demonstrated that no lymphatic complications occurred six months after EVLT, whereas one lymphatic complication occurred after cryostripping, however not in the groin but at the knee. PMID: 18361264 [PubMed - in process] http://www.ncbi.nlm.nih.gov/pubmed/18361264?dopt=Abstract ----------------------------------------------------------------------------------------------------- Br J Dermatol. 2008 Mar 20 [Epub ahead of print] Erysipelas as a sign of subclinical primary lymphoedema: a prospective quantitative scintigraphic study of 40 patients with unilateral erysipelas of the leg. Damstra RJ, van Steensel MA, Boomsma JH, Nelemans P, Veraart JC. Department of Dermatology, Phlebology and Lymphology, Nij Smelinghe Hospital, 9202 NN Drachten, The Netherlands. Background Erysipelas is a common skin infection that is usually caused by beta-haemolytic group A streptococci. After having had erysipelas in an extremity, a significant percentage of patients develops persistent swelling or suffers from recurrent erysipelas. We hypothesize that in cases of erysipelas without a clear precipitating agent, subclinical pre-existing congenital or acquired disturbances in the function of the lymphatic system are present. The persistent swelling after erysipelas is then most likely caused by lymphoedema. Objectives We designed a study to examine if erysipelas of unknown origin is associated with a pre-existent insufficiency of the lymphatic system. If our hypothesis is correct, patients with erysipelas of unkown cause without previously evident lymphoedema should have evidence of disturbed lymphatic transport in the unaffected extremity. Methods A prospective study, in which lymphoscintigraphy of both legs was performed in patients 4 months after presenting with an episode of erysipelas only in one leg. No patient had any known risk factor for erysipelas, such as diabetes mellitus, chronic venous insufficiency or clinical signs of lymphoedema. Lymphoscintigraphy was performed in 40 patients by subcutaneous injection of Tc-99m-labelled human serum albumin in the first web space of both feet. After 30 and 120 min, quantitative and qualitative scans were performed using a computerized gamma camera. During the lymphoscintigraphy, the patients performed a standardized exercise programme. Lymph drainage was quantified as the percentage uptake of Tc-99m-labelled human serum albumin in the groin nodes at 2 h after injection. Groin uptake of < 15% is pathological; uptake between 15-20% is defined as borderline, and uptake of > 20% as normal. Results The mean +/- SD percentage uptake in the groin nodes in the affected limbs was 9.6 +/- 8.5% vs. 12.1% +/- 8.9% in the nonaffected limbs. The mean paired difference in uptake between the nonaffected vs. affected side was 2.5% (95% confidence interval 1.1-3.9%). This indicates that lymphatic drainage in the nonaffected limb was only slightly better than in the affected limb despite the infectious event in the latter. Of 33 patients with objective impairment of lymph drainage in the affected limb, 26 (79%) also had impaired lymph drainage in the nonaffected limb. Agreement in qualitative measurements between affected and nonaffected leg was less pronounced: 21 patients had abnormal qualitative results in the affected leg of whom nine also had impairment of the nonaffected leg (43%). Conclusions Erysipelas is often presumed to be purely infectious in origin, with a high rate of recurrence and a risk of persistent swelling due to secondary lymphoedema. In this study, we show that patients presenting with a first episode of erysipelas often have signs of pre-existing lymphatic impairment in the other, clinically nonaffected, leg. This means that subclinical lymphatic dysfunction of both legs may be an important predisposing factor. Therefore, we recommend that treatment of erysipelas should focus not only on the infection but also on the lymphological aspects, and long-standing treatment for lymphoedema is essential in order to prevent recurrence of erysipelas and aggravation of the pre-existing lymphatic impairment. Our study may change the clinical and therapeutic approach to erysipelas as well as our understanding of its aetiology. PMID: 18363756 [PubMed - as supplied by publisher] http://www.ncbi.nlm.nih.gov/pubmed/18363756?dopt=Abstract -------------------------------------------------------------------------------------------- Growth Factors. 2007 Dec;25(6):417-25. A system for quantifying the patterning of the lymphatic vasculature. Shayan R, Karnezis T, Tsantikos E, Williams SP, Runting AS, Ashton MW, Achen MG, Hibbs ML, Stacker SA. Melbourne Tumor Biology Branch, Ludwig Institute for Cancer Research, Royal Melbourne Hospital, Victoria, Australia. The lymphatic vasculature is critical for immunity and interstitial fluid homeostasis, playing important roles in diseases such as lymphedema and metastatic cancer. Animal models have been generated to explore the role of lymphatics and lymphangiogenic growth factors in such diseases, and to study lymphatic development. However, analysis of lymphatic vessels has primary been restricted to counting lymphatics in two-dimensional tissue slices, due to a lack of more sophisticated methodologies. In order to accurately examine lymphatic dysfunction in these models, and analyse the effects of lymphangiogenic growth factors on the lymphatic vasculature, it is essential to quantify the morphology and patterning of the distinct lymphatic vessels types in three-dimensional tissues. Here, we describe a method for performing such analyses, integrating user-operated image-analysis software with an approach that considers important morphological, anatomical and patterning features of the distinct lymphatic vessel subtypes. This efficient, reproducible technique is validated by analysing healthy and pathological tissues. PMID: 18365872 [PubMed - in process]http://www.ncbi.nlm.nih.gov/pubmed/18365872?dopt=Abstract -------------------------------------------------------------------------------------------- Lymphology. 2007 Dec;40(4):157-62. MR imaging, proton MR spectroscopy, ultrasonographic, histologic findings in patients with chronic lymphedema. Fumiere E, Leduc O, Fourcade S, Becker C, Garbar C, Demeure R, Wilputte F, Leduc A, Delcour C. Department of Radiology, CHU Charleroi, Université Libre de Bruxelles, Belgium. eric.fumiere@belgacom.net Lymphedema is a progressive disease with multiple alterations occurring in the dermis. We undertook this study using high-frequency ultrasonography (US), magnetic resonance imaging, proton MR spectroscopy and histology to examine structural changes occurring in the subcutaneous tissue and precisely describe the nature of intralobular changes in chronic lymphedema. Four cutaneous and subcutaneous tissue biopsies from patients with chronic lymphedema during lymphonodal transplantation were studied. We performed US with a 13.5 MHz transducer, TSE T1 and TSE T2 magnetic resonance images with and without fat-suppression, MR Chemical Shift Imaging Spectroscopy and histological evaluation on these biopsies. We found that normal subcutaneous septa are seen as hyperechogenic lines in US and hyposignal lines in MRI and that hyperechogenic subcutis in US can be due to interlobular and intralobular water accumulation and/or to interlobular and intralobular fibrosis. Our study also confirms the usefulness of MR spectroscopy to assess water or fat content of soft tissue. Thus, multiple imaging modalities may be necessary to precisely delineate the nature of tissue alterations in chronic lymphedema. PMID: 18365529 [PubMed - in process] http://www.ncbi.nlm.nih.gov/pubmed/18365529?dopt=Abstract -------------------------------------------------------------------------------------------- South Med J. 2008 Feb;101(2):208-10. Surgical repair of idiopathic scrotal elephantiasis. Zacharakis E, Dudderidge T, Zacharakis E, Ioannidis E. Second Department of Urology, Aristotle University of Thessaloniki, Papageorgiou General Teaching Hospital, Thessaloniki, Greece. manoszacharakis@hotmail.com Scrotal lymphedema (scrotal elephantiasis) is uncommon outside of filariasis endemic regions. We present a case of a 65-year-old with idiopathic lymphedema of the scrotum and functional impairment of the penis. The patient underwent surgical excision of the edematous subcutaneous tissues and plastic reconstruction of his penis and scrotum. Three years later, the patient showed no signs of local recurrence, had complete restoration of urinary and sexual function and was extremely satisfied with the result. Surgical management was an effective strategy in the management of scrotal lymphedema in this case. PMID: 18364628 [PubMed - in process] http://www.ncbi.nlm.nih.gov/pubmed/18364628?dopt=Abstract ------------------------------------------------------------------------------------------ Lymphology. 2007 Dec;40(4):153-6.Related Articles, Links Lymphedema in China--experiences and prospects. Liu NF. Department of Plastic & Reconstructive Surgery, Shanghai 9th People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China. liun2002@yahoo.com The history of prevention and treatment of lymphedema in China is long. Filarial lymphedema was the most common type of the disease in the past with 5 million patients countrywide in the 1950's. Great efforts have gone into controlling filariasis during the past 50 years, and China now has essentially eliminated filariasis. In contrast to the reduction in filarial lymphedema, there has been a trend of increase in secondary lymphedema cases after malignant tumor surgery. Although there are no precise figures on the incidence of lymphedema nationwide, physicians and therapists are in great clinical demand. Traditional Chinese medicine has shown effectiveness for prevention and treatment of inflammation and alleviating swelling. The combination with Western medicine may offer improved methods for lymphedema treatment. PMID: 18365528 [PubMed - in process] http://www.ncbi.nlm.nih.gov/pubmed/18365528?dopt=Abstract -------------------------------------------------------------------------------------------- Lymphology. 2007 Dec;40(4):172-6.Related Articles, Links Lymphscintigraphy predicts response to complex physical therapy in patients with early stage extremity lymphedema. Hwang JH, Choi JY, Lee JY, Hyun SH, Choi Y, Choe YS, Lee KH, Kim BT. Department of Physical Medicine and Rehabilitation, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. We investigated whether baseline lymphscintigraphic findings can predict long-term response to complex physical therapy (CPT) in patients with early stage extremity lymphedema. Twenty patients with unilateral extremity lymphedema of clinical stage I or II underwent CPT after baseline lymphscintigraphy. Therapeutic responses (good vs. poor) were evaluated at 1 year post-CPT based on changes in skin status and subjective symptoms, and percent volume reductions and compared with clinical factors and lymphscintigraphic findings. Eleven patients showed good response to CPT with significant volume reduction of edematous extremities, and no significant volume reduction was observed in the remaining 9. Patients with good or poor responses to CPT showed no significant differences in terms of clinical variables. However, significant differences were observed between the lymphscintigraphic findings of these patients. More specifically, a lymphscintigraphic finding of main lymphatic vessels without collateral lymphatic vessels was the best predictor for a good response to CPT; the sensitivity, specificity and accuracy of this lymphscintigraphic finding is 91% (10/11), 100% (9/9) and 95% (19/20), respectively. In patients with unilateral extremity lymphedema of early stage, baseline lymphscintigraphy may usefully predict long-term response to CPT. Publication Types: Research Support, Non-U.S. Gov't PMID: 18365531 [PubMed - in process]http://www.ncbi.nlm.nih.gov/pubmed/18365531?dopt=Abstract ------------------------------------------------------------------------------------------------ Lymphology. 2007 Dec;40(4):185-7. Home volumetry foretells a new era of self-management for patients with lymphedema after breast cancer. Lette J, Lette F, Fraser S. Department of Nuclear Medicine, Maisonneuve Hospital, Montreal, QC, Canada. jlette@lette.com We designed a device for quick and accurate measurement of arm volume at home. The device is non-commercial, and plans for construction and use are widely available. A single subject with arm lymphedema used the volumeter at home for more than one year and learned to better self-manage her condition. She discovered that symptoms commonly associated with worsening lymphedema (painful, heavy arm) are often unrelated to arm volume, transient, and therefore require no treatment. She was able to customize treatment including measuring the impact of various treatments and devices on arm volume. In the previous summer, the subject experienced worsening edema, which required 5 weeks of intensive treatment. During the summer of the study, the subject found that as temperatures increased the decrease in arm volume she normally experienced at night reversed, resulting in a slow and gradual increase in edema. She then tested several therapeutic interventions and devices and found that wearing a Class 1 sleeve at night during the summer months was the most effective intervention to maintain her arm volume. We predict that home volumetry will be useful for the management of lymphedema and particularly allows patients an increased ability to manage their symptoms. PMID: 18365533 [PubMed - in process] http://www.ncbi.nlm.nih.gov/pubmed/18365533?dopt=Abstract ------------------------------------------------------------------------------------------------- Lymphology. 2007 Dec;40(4):188-90.Related Articles, Links Missteps when mice with lymphatically insufficient tails leap from molecular biology to human clinical lymphology. Földi M, Clodius L. Földiklinik, Freiburg, Germany. A cautionary note is provided about making translational leaps from molecular biology and murine lymphedema models to clinical lymphology. PMID: 18365534 [PubMed - in process]http://www.ncbi.nlm.nih.gov/pubmed/18365534?dopt=Abstract ------------------------------------------------------------------------------------- Lymphology. 2007 Dec;40(4):177-84 Quality of life and lymphedema following breast cancer. Heiney SP, McWayne J, Cunningham JE, Hazlett LJ, Parrish RS, Bryant LH, Vitoc C, Jansen K. Palmetto Health South Carolina Cancer Center, Columbia, SC 29203, USA. Sue.Heiney@PalmettoHealth.org The aim of the study was to compare Quality of Life (QOL) of breast cancer patients with and without secondary lymphedema (SLE) using a cross-sectional design with a convenience sample. Research packets were mailed to 2088 breast cancer patients (BrCaPt). The QOL component of the study used the Quality of Life Instrument --Breast Cancer Patient Version for data collection. The sample (n = 537) was 12.9% African-American/Hispanic/Other (AA) and 87.1% European-American (EA). One hundred and twenty-two women (22.7%) reported SLE. Overall and subscale means were computed and ANOVA was determined for seven variables: age, marital status, educational level, race, type of surgery, time since diagnosis, and SLE. Women without SLE had a higher overall mean QOL score compared to women with SLE (p= 0.02). Women with a greater than high school education had a higher mean QOL score compared to women with high school or less education (p=0.05). SLE patients had poorer QOL in the physical (p<0.001), and social (p=0.004) subscales. Older women had a higher overall QOL compared to younger women (p<0.001). These results provide insight into the impact of SLE on women's QOL and pinpoint that physical and social well being are negatively influenced by SLE. Publication Types: Research Support, Non-U.S. Gov't PMID: 18365532 [PubMed - in process] http://www.ncbi.nlm.nih.gov/pubmed/18365532?dopt=Abstract ----------------------------------------------------------------------------------------------- J Eur Acad Dermatol Venereol. 2008 Apr;22(4):409-16. Re-emergence of lymphogranuloma venereum. Kapoor S. glossomed@gmail.com Lymphogranuloma venereum (LGV) is a sexually transmitted infection caused by the L1, L2 and L3 serotypes of Chlamydia trachomatis. The disease has been in the spotlight recently because of recent outbreaks in Europe as well as the USA. A unique feature of the recent outbreaks has been that most cases have been caused by the L2 strain. Another unique feature of these outbreaks is the fact that most cases have occurred in men having sex with men, and most patients have presented with proctitis. Interestingly, most recent cases have occurred in human immunodeficiency virus-seropositive patients. Usually, the disease is divided into three phases: the primary stage characterized by a self-healing papule, the secondary stage characterized by proctitis or lymphadenopathy and the tertiary stage characterized by lymphedema and anal strictures. Tests used for diagnosis include polymerase chain reactions and compliment fixation tests. The treatment of choice is doxycycline. PMID: 18363909 [PubMed - in process]http://www.ncbi.nlm.nih.gov/pubmed/18363909?dopt=Abstract -------------------------------------------------------------------------------------------- |
| Breast Cancer-Related Lymphedema – What Are the Significant Predictors and How They Affect the Severity of Lymphedema?
Atilla Soran MD, MPH, , Gina D'Angelo PhD, , Mirsada Begovic MD, PhD, , Figen Ardic MD, , Ali Harlak MD, , H. Samuel Wieand PhD, , Victor G. Vogel MD, MHS, , Ronald R. Johnson, MD Breast Cancer-Related Lymphedema – What Are the Significant Predictors and How They Affect the Severity of Lymphedema? ... Abstract: According to the American Cancer Society, there are currently 2 million breast cancer (BC) survivors in the USA and 20% of them cope with lymphedema (LE). ... Arm lymphedema (LE) is one of the most common complications after breast cancer surgery and has been reported incidence varying from 6% to 30% (2). ... The Breast Journal, Volume 12, Issue 6, Page 536-543, Nov 2006, doi: 10.1111/j.1524-4741.2006.00342.x The Breast Journal Vol. 12 Issue 6 Page 536 November/December 2006 Breast Cancer-Related Lymphedema - What Are the Significant Predictors and How They Affect the Severity of Lymphedema? Atilla Soran MD, MPH, Gina D'Angelo PhD, Mirsada Begovic MD, PhD, Figen Ardic MD, Ali Harlak MD, H. Samuel Wieand PhD, Victor G. Vogel MD, MHS, Ronald R. Johnson MD The Pathogenesis of Filarial Lymphedema. Is it the Worm or Is It the Host? PATRICK J. LAMMIE, KAREN T. CUENCO, GEORGE A. PUNKOSDY The Pathogenesis of Filarial Lymphedema ... Our understanding of the pathogenesis of filarial lymphedema ... Recurrent bacterial infections play a major role in the progression of lymphedema ... Annals of the New York Academy of Sciences, Volume 979, THE LYMPHATIC CONTINUUM: Lymphatic Biology and Disease, Page 131-142, Dec 2002, doi: 10.1111/j.1749-6632.2002.tb04874.x Lymphedema of the Arm and Breast in Irradiated Breast Cancer Patients: Risks in an Era of Dramatically Changing Axillary Surgery Thomas E. Goffman, MD, Christine Laronga, MD, Lori Wilson, MD, and David Elkins, MS Lymphedema of the Arm and Breast in Irradiated Breast Cancer Patients: Risks in an Era of Dramatically Changing Axillary Surgery ... Key Words: axillary surgery, breast edema, breast irradiation, lymphedema ... The purpose of this study was to assess risk for lymphedema of the breast and arm in radiotherapy patients in an era of less extensive axillary surgery. ... The Breast Journal, Volume 10, Issue 5, Page 405-411, Sep 2004, doi: 10.1111/j.1075-122X.2004.21411.x |
