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Lymphland International Lymphedema Online
| AUGUST 2007 Published: August 31, 2007 12:00 am Treating the swelling effects of lymphedema By Rx for Health , Kathleen Edwards Eagle-Tribune Lymphedema is a very common condition affecting more than 3 million Americans. However, very few people have a true understanding of what it is. Lymphedema is the swelling of a body part. It is most often found in the arms and legs, but may also affect the face, trunk, abdomen or genital area. In order to classify swelling as lymphedema, the fluid must not only be water-based but also contain proteins. To understand where this fluid comes from and the significance of what it contains, you must first have an understanding of the lymphatic system and how it works. A two-layered system comprised of a superficial and a deep layer, the lymphatic system is present in all of our bodies. It consists of lymphatic vessels and lymph nodes that, with a few exceptions, run through all areas of the body with a blood supply. While lymph nodes vary from person to person, we average about 600 to 700 lymph nodes throughout our bodies. The majority are positioned in the intestines and head or neck area, where they act as a powerful line of defense against common entry ways for pathogens, better known as germs. Lymph nodes primarily protect us by filtering harmful materials like cancer cells, pathogens, dust and dirt, and improving immunity through the production of antibodies. The lymph vessels help to move the lymph fluid away from our vital tissues to the lymph nodes, taking along with it waste products, bacteria, dead cells and large cells that our body cannot transport or break down. Here, these waste products are broken down and destroyed, leaving any beneficial fluid to be transported back to our heart and lungs to re-enter the blood stream. There are multiple causes of lymphedema. One common type results from surgery or radiation used as part of cancer treatment. Other common causes can be surgical procedures in which lymph nodes are removed (i.e. mastectomies or lumpectomies) , trauma or infection of the lymph system, severe venous insufficiencies, and hereditary issues present at birth or triggered later in life at the occurrence of puberty or with pregnancy. Initially symptoms of lymphedema may be reduced by elevating the affected area. However, without proper treatment, lymphedema will continue to progress through its stages and worsen, leading to hardening of the affected area. As the limb grows progressively larger and harder, it becomes more prone to complications such as fungal infections. Many treatments are available. Most often, medicines such as diuretics are prescribed. But without additional treatments, diuretics have very poor long-term results and should not be used solely to treat lymphedema. Diuretics only help to remove water from the affected area, leaving the proteins behind. When a patient comes off the diuretics, the protein-rich area may attract the water once again, causing the swelling to return. Sometimes, pneumatic compression pumps can be used. However, if used alone, they also present downfalls similar to using diuretics without additional treatment. Pneumatic compression pumps temporarily remove the water, leaving the proteins behind to potentially attract more water once the pump is removed. In addition, the pump may actually destroy remaining functional lymph vessels, causing an increase in lymphedema with long-term use. Currently, the treatment of choice is complete decongestive therapy. This type of therapy consists of four components: manual lymph drainage, compression therapy, exercise and skin care. Manual lymph drainage is a gentle technique in which the accumulated fluid is manually moved out of the congested area and re-routed, sending the lymph liquid to a clear area where it can successfully move back into the body's normal circulation. Compression therapy, done through the use of bandages and compression garments, helps prevent future accumulation of fluid once it has been manually removed. Exercise is important in this method of therapy, if done properly. If the wrong exercises are performed, they can actually make the condition considerably worse. A trained professional will develop a customized exercise program designed to facilitate the use of muscle activity to push the fluid out of the affected limb. Finally, information is given on the importance of skin care and how to care for the swollen limb properly to avoid infection and avoid triggers that may cause the recurrence of lymphedema. When treated properly, lymphedema can be sent into remission. If patients initially receive proper treatment for this life-long condition and learn how to prevent its recurrence, they can return to their daily activities and a normal way of life. nnn Kathleen Edwards DPT, CLT is a doctor of physical therapy and certified lymphedema therapist at The Center for Rehabilitation and Sports Medicine at Beverly Hospital. Downtown Milford gets a new pink door By Alison Bergsieker STAFF WRITER Non-profit opens up shop There isn't anything more uncomfortable than wearing a paper dressing gown, sitting alone in a doctor's office and waiting for an expensive mammogram that could turn up positive for cancer. But there is one non-profit group working to make mammograms more affordable, while pampering those patients who need it most. And they've just moved in on Main Street. Julie Durham, owner and co-founder of the Pink Door, a non-profit organization helping women pay for mammograms to detect early warning signs of breast cancer, will open up shop at 239 N. Main St. on Aug. 24 in the old Shelton Windows building. Durham is a mammographer at Botsford General Hospital in Farmington Hills. After receiving countless calls from patients with no insurance or other situations who couldn't afford mammograms, she founded the Pink Door. "A lot of people out there are the working poor," Durham said. "We lose lives based on the fact that there's nothing there to help these women." Durham had been searching for a location in Highland for several months with no avail. She was sold when she came across the Shelton Windows building, which has a perfectly painted pink door. "God closed the door and opened the windows — Shelton windows," Durham said. "After we got every door slammed we ended up in downtown Milford." Debbie Shew, special services coordinator, said the store will carry an endless supply of "comfort." "We've got golf shirts, fleeces, robes, T-shirts, sweatshirts, pants — just a variety of clothing for men and women," Shew said. "We have a 'Sirvivor' line for men too." The store will sell T-shirts designed with a little door that opens across the chest, so patients can opt out of wearing the uncomfortable dressing gowns offered at hospitals. "When people have cancer, they don't feel good, and they don't feel pretty," Shew said. "Our goal is to help them out with that." There will be a few new editions too — Susan's Special Needs will offer pre-imposed mastectomies once a month, and other items available for purchase include a line of chocolates, radiation soothing creams, journals and attractive hats for patients who've lost their hair. Shoppers also can purchase a "Remembear," a teddy bear made with clothing of loved ones who've passed. "If someone happens to pass away, you can take a piece of their clothing, and we fashion a teddy bear out of it," Durham said. "The teddy bear will actually be named after the person." A massage therapist will be available for lymphedema patients who are suffering from fluid build up in their arms, Shew said. Shew and her husband, Larry, co-authored the book, "The Home Report Card," a book that lets family members fill out grading scales for each other. The couple will hold a book-signing at the store on Aug. 25. Durham will perform a ribbon cutting ceremony at the store on Aug. 24. The non-profit also will host a dinner theater event at 59 West on Aug. 23. For more information about the dinner theater contact Andrea Bronson at (248) 320-4585. Store hours are from 10 a.m. to 6 p.m. Wednesday and Friday, 10 a.m. to 7 p.m. Thursday and 10 a.m. to 4 p.m. Saturday. "This is for a great cause," Shew said. "There's nothing between Highland and Detroit that provides these services for both men and women." Alison Bergsieker is a reporter for the Milford Times. She can be reached by phone at (248) 685-1507. Precision Dynamics Corporation Offers Color Coded Alert Band Wristbands for Patient Safety SAN FERNANDO, Calif.--(BUSINESS WIRE)--Precision Dynamics Corporation (PDC), a leader and innovator of automated wristband identification, announces the release of color coded Alert Band Wristbands for patient safety. Throughout the United States, healthcare facilities have long used color-coded wristbands to signal important medical information. In fact, according to the 2005 Patient Safety Authority Survey of Pennsylvania Hospitals four out of five respondents’ facilities used color-coded patient wristbands. However, the lack of consistency in wristband meanings and how they are applied presents problems when patients are transferred among facilities and when patients are cared for by clinicians in multiple hospitals. This challenge was highlighted when a patient was nearly not resuscitated during a cardiopulmonary arrest because she was incorrectly designated “DNR” with a color-coded wristband by a nurse who worked in multiple facilities and was confused about the meanings of different colors.(a) Events such as these increase the risks of making potentially fatal patient errors. Precision Dynamics’ color coded Alert Band wristbands greatly minimize the chance of error by providing pre-printed, large visible text/cues and an extensive range of vibrant colors that allow healthcare workers to immediately identify patient medical conditions. Each band is equipped with PDC’s patented SecurSnap® closure for optimum patient comfort and safety. While at this time there isn’t a national standard assigning specific color wristbands to specific alerts, individual states such as Arizona, New York, Pennsylvania, Ohio and others are adopting standards, and PDC supports these and all patient safety initiatives. In support of these initiatives, PDC’s Color Coded Alert Bands provide maximum patient protection and comfort in one total wristband solution. PDC’s Color Coded Alert Wristbands provides healthcare professionals with the following advantages: Clear Visibility of patient alerts even if the patient shifts or the patient cannot be disturbed. SecurSnap® closures for patient security, safety and comfort. Flexibility in size for patient comfort. Custom printed text to fit any standardized level now and in the future. Custom alert logos to allow for less common conditions such as “Limb alert” or “Lymphedema Alert” etc. Latex-free. For more information on PDC’s color Alert Bands, please visit call 800-772-1122. For media inquiries and requests for hi-resolution product photos, please contact: Adrienne S. Lamm at 818-897-1111 ext. 1330 About Precision Dynamics With over 50 years of experience, PDC is a global leader and pacesetter in the development of Auto ID wristband systems for healthcare, leisure and entertainment, and law enforcement. The company introduced the first patient Bar Code ID Wristband, patented Smart Band® Radio Frequency Identification (RFID) Wristbands, the AgeBand® Age/ID System, and PDC Smart Kiosk® Cashless RFID System. PDC is committed to 100% quality in service, design, and manufacturing and has ISO- 9001: 2000 and ISO-13485: 2003 certification. For more information, visit www.pdcorp.com. Precision Dynamics Corporation name and logo, Securline®, SecurSnap®, Smart Band®, AgeBand®, and PDC Smart Kiosk® are registered trademarks of Precision Dynamics Corporation. All other product names, company names, marks, logos and symbols mentioned herein are trademarks of their respective owners. A surgeon at the University of Arkansas for Medical Sciences (UAMS) has developed a new procedure to prevent one of the most common side effects associated with breast cancer treatment lymphedema or swelling of the arms due to faulty drainage of the lymph nodes. V. Suzanne Klimberg, M.D., director of the UAMS breast cancer program, led a study funded by the Tenenbaum Breast Cancer Research Foundation of breast cancer patients at risk for developing lymphedema. Her findings were published in the February issue of the Annals of Surgical Oncology, and she will present the study March 17 at the Society of Surgical Oncology 60th Annual Cancer Symposium in Washington, D.C. "The removal and analysis of the lymph nodes under the arm remains the most important factor in determining the severity of disease in breast cancer patients," Klimberg said. "In the past, surgery to remove the lymph nodes and most of the fat and tissue in the armpit often resulted in complications, including lymphedema." Five percent to 50 percent of women undergoing surgical treatment for breast cancer have developed lymphedema, mainly dependent upon the extent of surgery. At the ACRC, surgeons determined that the draining of the first lymph node, known as the sentinel lymph node, is capable of predicting if the cancer has spread to the remaining armpit lymph nodes, known as axillary lymph nodes. This is a less invasive surgery and reduces the likelihood of complications. However, the lymph node system is at risk of disruption during either a sentinel lymph node biopsy or an axillary lymph node dissection, which often leads to swelling in the arm. To prevent the arm swelling, Klimberg has developed the Axillary Reverse Mapping (ARM) procedure. The new technique evaluates the ways in which fluid drains through the lymph node system in the arm through the injection of blue dye. The dye is used to map the drainage of the arm. "Mapping the drainage of the arm decreases the chances of unintended disruption of the lymph node system during surgery and reduces the risk of developing swelling in the arm," Klimberg said. "We are the first to study lymph node drainage in the arm and are now using the ARM procedure as standard procedure at UAMS." Klimberg will soon begin conducting training seminars on the procedure throughout the country. The seminars will be sponsored by the global medical device company Ethicon, a branch of Johnson & Johnson. Klimberg is chief of the Division of Breast Surgical Oncology at UAMS and a professor in the Departments of Surgery and Pathology. She also is director of the Breast Cancer Program at the UAMS' Arkansas Cancer Research Center as well as director of Breast Fellowship in Diseases of the Breast at UAMS. Additional UAMS staff members involved in the published study are Kent Westbrook, M.D.; distinguished professor; Ronda Henry-Tillman, M.D., associate professor of surgery; Margaret Thompson, fellow; Soheila Korourian, M.D., associate professor of pathology; Keiva Bland, fellow; K. Jackman, surgery resident; and Laura Adkins, data manager. UAMS is the state's only comprehensive academic health center, with five colleges, a graduate school, a medical center, six centers of excellence and a statewide network of regional centers. UAMS has about 2,430 students and 715 medical residents. It is one of the state's largest public employers with about 9,400 employees, including nearly 1,000 physicians who provide medical care to patients at UAMS, Arkansas Children's Hospital, the VA Medical Center and UAMS' Area Health Education Centers throughout the state. UAMS and its affiliates have an economic impact in Arkansas of $5 billion a year. University of Arkansas for Medical Sciences 4301 W. Markham St., Slot 716 Little Rock, AR 72205 United States --------------------------------------------------------------------- 83-year-old’s fundraising efforts for disease victims By Nicola Fifield Eileen Rhodes, 83, is fundraising for MacMillan Cancer Support. LIFE has been full of heartbreak for a mother-of-two, who has lost two husbands to cancer and is now facing her own battle with a non-curable disease. But despite the rough deal life has dealt her, Eileen Rhodes is more concerned about the suffering of other people - and has raised thousands of pounds for charities over the years. The 83-year-old, who lives off Poppleton Road, in York, had only one week to say goodbye to her first husband, Jim Smart, who died of prostate cancer in 1983. She said: "We were living in the Scottish Borders at the time. He suddenly fell in and was rushed to hospital in Edinburgh, where he was told he had a week to live. "I was devastated. Neither of us had any idea he had cancer until that moment. It was so sudden. "During that last week he was unconscious throughout and I couldn't even say goodbye properly. That was very upsetting." advertisement Eileen, who is a retired special needs teacher, met Jim when she was 23 and they had been married for 40 years before his sudden death. She said: "After Jim died, I said to my children that I would never get married again. But I moved to York and started working as a volunteer at the St Sampson's Centre and it was there I met Cliff. "After losing Jim, it was so wonderful to be happy again. Cliff was one of those rare gems - everybody loved him. "He proposed to me under the Queen Mother's portrait at the centre and we were married in 1985. For our honeymoon, we went to California. It was so romantic." But her happiness was short-lived after Cliff also fell ill in 1994 - and was diagnosed with leukaemia at York Hospital. Eileen said: "We had just one month together after he was diagnosed before he died. I can't really describe the pain, I was completely devastated. "But I knew I had to get on with my life. My motto has always been to keep going." A year after Cliff's death, Eileen developed the incurable condition lymphedema, which causes her legs to swell to three times their usual size due to an abnormal collection of lymph fluid in her body tissues. She said: "There's no point in feeling sorry for myself because I know there are many people far worse of than myself. "Lymphedema isn't life-threatening, but every day a district nurse has to come to my home to dress both my legs. "It gives me some pain in my back because it increases your body weight so much, but I'm still active." Eileen now focuses all her efforts on fundraising for Macmillan Cancer Support, which provides medical, emotional and financial support for cancer patients and their families. On Saturday, September 29, she is holding a marathon coffee morning at 26 Prior's Walk, in York, from 10am to 6pm. 10:46am Saturday 8th September 2007 CommentPosted by: Tina of Lymphland, New York State USA on 4:17am today Eileen, I'm sorry you lost your husband, what you are doing for the fundraising is awesome. I do have to say though that what you said about lymphedema not being life threatening is not 100% correct. We have to be careful of infections called cellulitis which can and are deadly. I have know 3 people in my group who have lost relatives due to cellulitis, so please be careful. I own Lymphland.com and Lymphland International Support Group, you and anyone else interested can join, the button to join is on the front page of Lymphland.com We have a chatroom that is open daily and alot of information about all aspects of lymphedema and living with the condition. Education is the best thing you can do for any condition especially lymphedema. Tina Budde of Lymphland Treating lymphedema Rezin Orthopedics is the last option for some patients September 5, 2007 Roberta Messmer, of Morris, thought her ordeal with cancer was long over. She had a mastectomy some 22 years ago when she was only 48 and was cancer-free. But after slipping on some wet grass about 13 years ago and breaking her fall with her left arm, she started noticing some swelling in her arm. Lymphedema patients must continue their at-home treatments the rest of their lives. ( At first she just thought it was from the fall itself, but she came to realize that her swelling had its roots in her cancer. Nineteen of Messmer's lymph nodes had been removed during her mastectomy, causing permanent damage to her lymphatic system. Her body had coped with her compromised lymphatic system for years, but the fall had added just enough overload to her lymph system that inflammation and swelling ensued. Her arm and hand swelled so much she had to have her wedding ring cut off her finger. Messmer's situation is not unusual. She had developed lymphedema, an abnormal accumulation of tissue fluids in the soft tissues of the body. Horrendous timing The irony is, just when many recovering cancer patients think their difficult ordeals are over, lymphedema rears its ugly head. American Cancer Society's statistics show that one third of women who have lymph node dissection suffer from lymphedema symptoms. Most commonly seen following breast cancer interventions, lymphedema can also occur after ovarian and cervical cancers. Men can get it after prostate or testicular cancers. Lymphedema can also appear with surgeries, infections, diabetes and some cardiac disorders. A person can be born with lymphedema, too. Doctors often refer to it as "thick legs." Traditional treatments for lymphedema have included diuretics and compression pumps. Julia Rodrick, a master clinician and lymphedema expert at the Hand and Lymphedema Center, a branch of Rezin Orthopedics and Sports Medicine in Morris and Ottawa, believes there is a better way. Rodrick uses manual lymph drainage and complete decongestive therapy. This is a combination of manual tissue techniques, exercise and special compression garments and wraps. Rodrick says she sees many patients who come to her as a last option after seeing health care professionals who do not fully understand the latest treatments. "Lymphedema is not something people have to live in misery with," Roderick says. "It is not curable, but it's manageable. There is hope, and we are excited to get the word out." Common symptoms Rodrick has studied lymphedema treatments with Dr. Michael Foldi in Germany, a leader in the field of lymphology. She's been using his methods successfully on patients since 1999 and has assisted in developing treatment programs throughout Illinois. Symptoms of lymphedema usually begin with a slight swelling in the arms and legs. Rings on the fingers might be tight, or there might be difficulty fitting into a shirt sleeve or pant leg because of the swelling. Left untreated, the limb can grow larger, swelling with fluid and protein trapped in the soft tissues. Cases have turned into major disabilities, disfigurement and even dangerous infections, such as cellulitis. Lymphedema can cause hard-to-heal wounds in limbs, too, leading to complications. The first week Rodrick sees a lymphedema patient she does the treatments daily. After that, she teaches her patients how to do the manual techniques and exercises themselves at home. They return now and then to perfect their techniques. Lymphedema patients must continue their at-home treatments the rest of their lives. When Roberta Messmer finally came to Rodrick for her lymphedema, her goal was to get her arm down to a nice size to fit into a special dress she had bought for an Alaskan cruise for her 50th wedding anniversary. By the time her treatments were through she was able to wear the dress. "It was just such an improvement over the previous therapy I had," she said. "Julia just really knows her stuff. She did a great job." For more information, contact Rezin Orthopedics and Sports Medicine at (815) 318-5650. -------------------------------------------------------- Reported September 14, 2007 Freezing Away Cancer BALTIMORE, Md. (Ivanhoe Broadcast News) -- Many people think of heartburn as something that's slightly uncomfortable. But for some people, it can develop into a life-threatening condition. Years of heartburn forced Bill Mohler to trade in orange juice for coffee at breakfast. "One of my vices is coffee," he says. "I drink about three cups a day." After 50 years of acid reflux, Mohler was still shocked to learn he'd developed Barrett's esophagus -- a condition where acid eats away the esophagus' lining and precancerous cells grow in their place. "They couldn't have cured it," Mohler says. "It would have become cancer." But timing was on Mohler's side. He soon found out he was eligible to take part in a pilot study testing a new device designed to kill precancerous cells. "The low-pressure spray liquid nitrogen is a new technique," says Bruce Greenwald, M.D., a gastroenterologist at the University of Maryland Medical Center in Baltimore. During the procedure, doctors anesthetize patients, send an endoscope down the esophagus and spray the abnormal area with liquid nitrogen. The liquid nitrogen freezes the bad cells and kills them. Doctors let the cells thaw for 45 seconds before spraying and thawing the area three more times. "The patients tolerate the treatment very well," says Dr. Greenwald. "We're seeing a regression of the bad cells." The procedure takes about 20 minutes, and patients feel little discomfort. In fact, they're usually up and about the same day. Dr. Greenwald says the results of the study are promising. "To some degree, [the procedure] helped everyone," he says. Larger trials will now be conducted at several hospitals to confirm the results, and patients like Mohler will continue to be followed. For now, Mohler's bad cells are gone, and he feels great. "I'm blessed," he says. "It's almost like hitting the lottery." Now, he and his wife can enjoy the retirement they always planned on. If you would like more information, please contact: Karen Warmkessel Public Relations University of Maryland Medical Center (410) 328-8919 http://www.ivanhoe.com/channels/p_channelstory.cfm?storyid=16959 -------------------------------------------- Recovery through rhythm -- Lebed Method of exercise helps breast cancer survivors By: PATTY McCORMAC - For the North County Times "Surviving is important, but thriving is elegant." That is the motto of Sherry Lebed Davis, one of the founders of The Lebed Method, a program of movement and dance that helps women heal emotionally and physically after breast cancer surgery. She and her two brothers created the program when their mother became depressed after breast cancer surgery in 1979. Lebed Davis, who was formerly a professional dancer with dance studios, used it nearly 20 years later when she herself underwent surgery for breast cancer. The method is so effective that it is practiced today in about 600 hospitals worldwide, she said. And because of growing interest, Lebed Davis will be visiting North County this week to provide a three-day certification program for new teachers and to refresh the skills of existing ones. "We need teachers. California is a big state, and there are a lot of hospitals we need to get into," Davis said. Two main goals The Lebed Method helps reduce two common side effects experienced by breast cancer survivors ---- frozen shoulder, a surgical complication, and lymphedema, or swelling of the lymph glands. "Both of these complications result in a decreased range of motion in the upper body. We have found that the ... classes prevent or minimize this loss of mobility," wrote Simone R. Zappa, a registered nurse and administrator of the Integrative Medicine Service at Memorial Sloan-Kettering Cancer Center in New York City. She was quoted in Radiology Today magazine in 2001. Locally, the Lebed Method is taught at Sharp Hospital in San Diego by Rancho Bernardo resident Terri Wyatt, a registered nurse and the hospital's oncology case manager. She said the exercise and restoration of mobility are not the only positive results of the class. "It is a support group. They bond with each other, and there is a lot of camaraderie," she said. Isobel Chisum of San Carlos, who has been following the program for almost a year now at Sharp Hospital in San Diego, agreed. She and her husband, Bill, met Lebed Davis on a cruise ship where she was teaching the method. Isobel, 71, had been diagnosed with breast cancer the day before leaving for the cruise and had surgery the day after returning. "This has helped with lymphedema (swelling), plus it is uplifting and very much fun, and it's great that my husband can come and support me," she said. Open to all Classes are not limited just to breast cancer survivors. "We open the classes to the community," Wyatt said. According to the Lebed Method Web site, classes are also offered at fitness centers, dance centers, churches and wellness centers nationally. Other local sites include Scripps Center for Integrative Medicine in La Jolla; the U.S. Naval Hospitals at Camp Pendleton and in San Diego; the Green Cancer Center in La Jolla; and through the California Multiple Sclerosis Society. Laurie Mort, who teaches the method at Inner Strength Yoga in Oceanside, said it is very gentle exercise. "Another byproduct of the program is that it creates a positive environment and positive reinforcement, which is a big part of the program as well," Mort said. And positive reinforcement is important. Lebed Davis recalled how devastated her mother had been after her cancer surgery. "My mom used to be a ballroom dancer with my dad, and after surgery she couldn't hook her bra and she couldn't brush her hair. She was from that era of Marilyn Monroe, when breasts were a symbol of sexuality. She went into a crash kind of depression." A family creation Lebed Davis's two brothers, Marc and Joel Lebed, both surgeons at Albert Einstein Medical Center in Philadelphia, wanted to help their mom. "They said, 'Let's all get together: You bring the dance and we will put together a program that is medically sound,' " said Lebed Davis. "So we put together a program for my mom. "Our house was always filled music and dance. That is how my brothers were raised, and they always felt there was more to medicine than just medicine." The results were so impressive that her mother's doctor wanted to know what she was doing and adopted the program at Einstein. In 1996, Lebed Davis underwent surgery for breast cancer. "Recovery was very hard for me. I couldn't move my arm. I called up my brother and said 'I'm so depressed. I don't know what to do.' He said, 'Sherry. Do your program.' It was like, 'Duh.' " That experience convinced her to quit her job as director of marketing for a health care company and devote herself full-time to the Lebed Method. Since then, she said, the program has helped thousands. Lebed Davis will teach Wyatt's class at 10 and 11 a.m. on Thursday at the outpatient pavilion at Sharp Hospital, 3075 Health Center Drive, San Diego. From 8 a.m. to 5 p.m. Friday through Sept. 16, she will give the certification class at Inner Strength Yoga, 2124 El Camino Real, Oceanside. The cost of the three-day class is $500, but scholarships are available to those who might not be able to afford the full fee. Those interested in taking the class for instructors need no prerequisites, Lebed Davis said, and no special skills other than wanting to help others not just to survive, but to thrive. "To me, surviving is just barely holding on," Lebed Davis said. For more information, call (877) 365-6014 Patty McCormac is a freelance writer. SCO Breast: Lymphedema Diagnosis Should Take Patient Perception into Account By Crystal Phend, Staff Writer, MedPage Today Reviewed by Zalman S. Agus, MD; Emeritus Professor at the University of Pennsylvania School of Medicine. September 10, 2007 Add Your Knowledge™ Additional ASCO Breast Coverage SAN FRANCISCO, Sept. 10 -- Arm measurements alone may not identify clinically relevant lymphedema for breast cancer patients after axillary lymph node dissection or sentinel biopsy, researchers said. Action Points Explain to interested patients that the study suggests lymphedema may be experienced even in the absence of changes in arm circumference after axillary lymph node surgery. This study was published as an abstract and presented orally at a conference. These data and conclusions should be considered to be preliminary until they have been published in a peer-reviewed publication. Lymphedema prevalence was 16% to 27% after axillary lymph node dissection and 3% to 5% after sentinel lymph node biopsy in a large study presented here at the American Society of Clinical Oncology's Breast Cancer Symposium. However, patient perception of swelling often did not correlate with clinical measurement, reported Sarah A. McLaughlin, M.D., of Memorial Sloan-Kettering Cancer Center in New York, and colleagues. Only 52% of patients with arm swelling of more than 2 cm reported experiencing it, whereas twice as many reported symptoms in their dominant arm as actually had measurable swelling (P=0.002). Diagnosis "should incorporate both measurements and patient perceptions," Dr. McLaughlin said. Although "lymphedema is one of the most feared complications of breast cancer surgery," definition and measurement of this complication have not been standardized, leading to wide ranges for incidence, she noted. Her group prospectively followed 936 women with clinically node-negative breast cancer for a median of five years after they had sentinel lymph node biopsy (600, mean three nodes removed) or lymph node biopsy followed by axillary lymph node dissection (336, mean 19 nodes removed). Measurements of both arms were taken for all women before the procedure and at follow-up. Lymphedema was also determined by patient report of perceived arm swelling during a standardized interview that also elicited risk factors and precautionary behaviors. The prevalence of lymphedema was higher for axillary lymph node dissection than for sentinel lymph node biopsy regardless of the method used to define lymphedema. The respective findings were: 16% for axillary lymph node dissection versus 5% for sentinel lymph node biopsy when defined by arm swelling of more than 2 cm (P<0.0001). 27% versus 3% when defined by patient perception only (P<0.0001). 16% versus 4% when defined by a validated instrument (P<0.0001). Although clinical measurement and patient perception agreed in most cases (786 without and 45 with), there were 64 women who perceived swelling without measured swelling of more than 2 cm and 41 women who had measured swelling without symptoms. Notably, symptomatic lymphedema was experienced by only 52% of patients with clinically measured swelling (45 of 86). Risk factors for lymphedema included higher body weight (P<0.0001), higher baseline and current body mass index (both P<0.0001), infection since surgery (P=0.004), and injury since surgery (P=0.03). Surgery in the dominant arm was not a risk factor (P=0.46), but may impact the way women perceive lymphedema, Dr. McLaughlin said. The difference in prevalence was most pronounced in women's dominant arm; 37 perceived swelling when there was no clinical swelling and 15 had swelling without sensing it (P=0.002). The difference was not significant for the non-dominant arm (27 versus 26, P=0.89). "This suggests that patients having axillary surgery ipsilateral to their dominant arm may be more sensitive to subtle changes in arm measurements or may be more significantly affected by sensory changes in that arm," she said. Overall, most women were careful to avoid activities that could contribute to lymphedema. Avoidance behaviors averaged 5.1 among women who had an axillary lymph node dissection, whereas those who had sentinel lymph node dissection practiced 4.3 of these behaviors on average (P<0.0001). The women most commonly avoided intravenous catheters (99% and 81%, respectively), blood pressure measurement (98% and 82%), and blood draws in the affected arm (99% and 82%). They also commonly avoided carrying a purse on the affected arm (33% and 26%) and picking up children (9% and 8%). A substantial proportion of women who had had an axillary lymph node dissection also wore a compression garment on the affected arm (15%). The clinical significance of one additional precautionary behavior is unknown and impact on quality of life warrants further study, she said. Future studies should also correlate the number of nodes removed with lymphedema, commented Emiel J. Rutgers, M.D., Ph.D., of the Netherlands Cancer Institute in Amsterdam, who was a chair of the session at which the study was presented. The researchers provided no information on conflicts of interest. Complete ASCO Breast Coverage Primary source: ASCO Breast Cancer Symposium Source reference: McLaughlin SA, et al "Prevalence of lymphedema in 903 women with breast cancer 5 years after sentinel node biopsy or axillary dissection: Measurements and patient perceptions" ASCO Breast 2007; Abstract 145. Managing chronic pain: Some things really do help Their chronic pain may not go away, but they've found a way to fight through it and keep going 12:00 AM CDT on Tuesday, September 11, 2007 By NANCY CHURNIN / The Dallas Morning News For the lucky ones, pain is a passing thing. REX C. CURRY/Special Contributor Breast-cancer survivor Bettye McQueen receives treatment from massage therapist Jane Kinman at Harris Methodist Hospital's Healing Arts Center. Ms. McQueen began receiving massage therapy after her cancer treatment to help alleviate pain from lymphedema. It's a problem with a solution: Take the right medication; get on the right health and fitness program; wait for the wound to heal, the fever to pass, the bone to set. But there are many for whom the aches, the stiffness, the sensitivity will never fully go away. It can be managed and minimized, but for people with chronic pain, life is a battle that requires constant vigilance, courage and a love of life that refuses to surrender. JUAN GARCIA/DMN A complication from a twisted ankle kept 14-year-old Megan Valdez from being active. Treatment and therapy have lessened the pain and taught her to minimize the pain she still feels. Helping them in their journey is the growing field of pain management. We talked with four patients and their doctors and therapists about how to put chronic pain in its place and keep it from interfering with life. They shared their hard-won knowledge, which took a couple of them decades to acquire, about how essential it is to get the proper medical care, to consider complementary alternative therapies, to exercise even when it hurts and to draw on the emotional support of family and friends through the tough times. Here are their stories. Bettye McQueen, 56, lymphedema MIKE STONE/Special Contributor A lumbar spinal-cord stimulator has helped Don Bell control chronic back pain. A breast cancer diagnosis in 1996 was a shock for Bettye McQueen of Grand Prairie. But even the lumpectomy, chemotherapy and radiation did not prepare her for the pain that hit a year ago. LOUIS DeLUCA/DMN Lifestyle changes and a positive, aggressive attitude help 68-year-old Bob Johnston live with the pain of rheumatoid arthritis. "I don't have any movement in my left hand or my thumb at all. And the pain was so bad, I could hardly bear it." It turned out that she had developed lymphedema, a condition in which a body area collects protein-rich fluid that causes it to swell. It can be caused by trauma injuries, such as the surgery for carpal-tunnel syndrome that Ms. McQueen had just before the pain started. Breast-cancer patients are at particular risk if they have had their lymph nodes removed, as Ms. McQueen did. MIKE STONE/Special Contributor 'I used to have a walker to get from room to room, and now, I can walk throughout the house,' Don Bell says. She's grateful, she says, for the Healing Arts Center at Harris Methodist Fort Worth Hospital, where she is learning the benefits of massage therapy, reflexology, lymphedema therapy and aromatherapy under the guidance of Ellen Kerr, a registered nurse and licensed massage and lymphedema therapist. "It surprised me that the massage therapy, along with the lymphedema therapy, reduced the amount of swelling, which reduced the pain," Ms. McQueen says. "I've been able to reduce the amount of pain medication." That's given her hope. "I'm feeling much better, and I'm hoping to get back 100 percent. They've told me they can't make any guarantees. But along with the therapist and my faith in God, I feel I can get total use in my arm and hand again. I have the fighting spirit, and I intend to fight this." Her advice: Study your condition: "There are women out there who don't even know there is treatment for lymphedema. Consult with your physician on how to get relief." She suggests seeking out complementary methods, "because sometimes we can help manage pain in different ways." Therapy is work: "You have to take on extra pain if you want to get better. I go to therapy every day, Monday through Friday. By the time I'm finished, I'm so wiped out I have to lie down and rest. But while it's painful going through it, in the evenings when I sit down to rest, the pain isn't there. I also have exercises they've given me to do at home. They're painful, but I'm resolved to do them." Family support: "I have three nieces and a brother and friends. They have taken time off from work to take me to my treatments. You don't know how that makes you feel that someone thinks enough of you to take time off from his job to take you where you need to be." Don Bell, 69, lumbar spinal stenosis Don Bell of Lucas has suffered from back problems for 35 years. As a young man, he compensated for spinal weakness by working out. But when he went into sales to support his wife and five children, the sitting reduced the muscles that had been keeping his back straight. He developed chronic pain syndrome and lumbar spinal stenosis – a narrowing of the back spinal canals that causes compression of the nerve roots. At age 40, Mr. Bell had the second of two back surgeries to alleviate the condition, but he was left with so much pain that he could barely get out of bed for the next two years. "It became a depressing situation. You can't sleep good, so you don't care to go to bed," he says. "Then it's hard to face the day. The hardest part is that I had to stop being active with my kids, and I couldn't carry any of my grandchildren. That's a big part of my life I had to miss. That makes me ache." He suffered for years until someone at his health club advised him to look into pain management. Mr. Bell had never heard of that field. Then he met Dr. Jerry W. Lewis, a pain-management specialist at Baylor Regional Medical Center at Plano, who "turned my life around," he says. Dr. Lewis gave him injections that alleviated the nerve pain and told him he was a good candidate for a lumbar spinal-cord stimulator, which Mr. Bell had implanted in his back six months ago. The implant blocks the pain signal at the spinal cord before it reaches the brain, so the brain doesn't recognize the pain. Mr. Bell says he feels 80 percent to 90 percent better. The stimulator also helped correct his posture. "I used to have a walker to get from room to room, and now, I can walk throughout the house," he says. "Recently, I was playing golf with my son. It's the first time I've played golf in more than 10 years." Mr. Bell also enjoys his job as a security guard at Allen High School. Before the implant, he worried that he might not be able to continue. Now, if he sits too long, all he has to do is reach for the bionic implant, "crank it up for five minutes," and it relieves the pain. "I love it," he says. "I get to intermingle with all the teenagers. That's an experience!" His advice: Family helps: "I married a good woman. And all our children built homes around us. I have 13 grandchildren, and they like to come over on weekends. We're so blessed." Take care of yourself: "I had to lose some weight and start exercising. That got me through several years. Now that I feel better, I can start exercising again, and I think I will be much better off." Embrace technology: "My wife got me a PlayStation for Christmas, and my grandsons and I really enjoy playing while I charge my bionic implant. I always keep this unit with me. I hook it around my belt like a cellphone." Bob Johnston, 68, rheumatoid arthritis Bob Johnston first noticed that something was wrong during a trip from Oklahoma to the State Fair of Texas 28 years ago. His legs were cramping, and he struggled to walk. He had no idea then that he had rheumatoid arthritis, a condition in which painful, widespread inflammation leads to an increased risk of heart disease and early death. And that it was going to get worse, a lot worse. "I didn't know what it was for a couple of months," says Mr. Johnston, who now lives in Farmers Branch. "It just devastated me. Once you get in that cycle of pain, stress and fatigue, it's real hard to get out of it. If you're not seeing a good doctor who knows what he's doing, and you're not on good medication, it will drive you to despair." He consulted a series of doctors, some more helpful than others. Among "the others" was one who prescribed liniment used for racehorses. Mr. Johnston has tried various medications over the years and is very happy with the ones prescribed by Dr. Yijun Fan, a rheumatologist at Presbyterian Hospital of Dallas. After a stroke in 2000, he followed Dr. Fan's lifestyle advice, too. He had been a smoker, so he quit. He gave up red meat in favor of turkey and chicken. He retired, started exercising and began taking time to enjoy life. He recently returned from a cruise he and his wife took to celebrate their 25th wedding anniversary. No doubt about it, he says, he feels better at 68 than he did at 45. His advice: Get help: "You've got to find a good physician and have support at home, because you're not going to always feel up to things. When you're in pain, sometimes just putting on your pants can be a struggle." Don't give up: "The alternative isn't good. You can't just sit there and feel sorry for yourself. I'm not brave, but I feel better when I get on the treadmill about 30 minutes every other day." It gets better: He retired six years ago, which, he says, reduced his stress level. That lifestyle change, along with giving up smoking, making more healthful food choices and exercising, has helped a lot. "I've been lucky," he says, noting that it's important not to give up, because by taking the right steps and getting the proper help and support, things can improve over time. Megan Valdez, 14, complex regional pain syndrome In March 2006, Megan Valdez twisted her ankle in gym class. But as the ankle healed, the pain got worse. She began using one, then two crutches. It hurt when air from a fan hit the ankle. Putting on her shoes and socks was excruciating. Megan had developed complex regional pain syndrome. In the condition, diagnosed by the multidisciplinary pain-management clinic at Children's Medical Center Dallas, the nerves don't get the message that the injury has healed. Symptoms include swelling, a change in skin color, a change in nail and hair growth patterns and a cool temperature at the original injury site. The diagnosis was a relief, the Lewisville teen says, because it meant that she would get help and had an answer for kids who teased her for making "a big deal" out of what they thought was nothing. "I would cry a lot because it would be hurting," Megan says. "People thought I was lying. I felt sad, and I would get mad because people were not believing me." Understanding the condition didn't make the pain itself easier to handle, however. Dr. Alan Farrow- Gillespie at Children's gave her spinal blocks and inserted an IV line for epidural injections when needed. After the hospital treatment, she struggled to do intensive physical therapy at Greater Lewisville Therapy Center for a year. "I would always want to stop because it hurt so much. Sometimes, I was crying at physical therapy, but my physical therapist was very nice and would always make me laugh." It's been hard, too, to accept that the pain will never fully go away. But Megan is happy because, on Aug. 20, she did something she never thought she'd do again. She ran a half-mile around her neighborhood. "At the beginning, I thought I would always be on crutches. Now, I feel better about myself. I'll be happy when I start school and can be in athletics because I love playing volleyball." Her advice: Face it: At first, Megan wanted to do anything she could to avoid the pain, including exercises that made her foot hurt. But now she's glad she persevered. And she's made peace with it. "I'm OK with the pain. I can fight through it because distraction is the best thing for it." Love that bro: It's hard when others don't believe you. That's why it means so much to have family members who understand. Megan's brother, Mark, now 10, "was very supportive" and would get things she needed when it hurt too much for her to move. Tough love helps: On orders from the doctor and therapist, Megan's parents would touch her injured foot. "I would start crying, and they would keep doing it. My mother said it was tough love because they were trying to help me get better." Tuesday, September 11, 2007 Shop offers dose of dignity for patients By BLYTHE BERNHARD The Orange County Register A boutique specializing in products for breast cancer patients and new mothers recently opened alongside Saddleback Memorial Medical Center in Laguna Hills. Transitions for Women, which is sponsored by the nonprofit hospital, offers custom-fitted bras, prosthetics, wigs, scarves and more. Compression garments for women with lymphedema are also available. Items for nursing mothers include specialty bras, pumps and pads. Mary Bowman, a registered nurse and manager of the boutique, talks about the new store and how it will serve women in Orange County. Q: How did the idea for the separate store come about? A: Our vision was basically continuum of care. We wanted to be able to provide a full-service cancer center. We wanted a full line for women. It was very frustrating for them and for us to have to send them to three different places to get the things they needed such as mastectomy bras, (arm) compressions and wigs. Q: Where do women typically find these items? A: Some went to department stores, some went to pharmacies, some went to wig stores. The problem was they had to go to different places to find different things. It's such an emotional time in a woman's life. Transitions represents our commitment to fulfilling all of a woman's health care needs, whether it's motherhood or facing cancer. Q: Can you describe the store? A: It doesn't look clinical, which is what we wanted. It's lavender, very warm colors. It's 2,000 square feet. We have a wig room. When they're in that room they're in there by themselves. If they want to be fitted for a bra or a prosthetic, that's also a separate room. They need their dignity. We wanted them to be able to come in and try on hats and try on wigs without everyone else there as well. When they would go into a regular store, there would be other people around. We definitely felt there was a need in the community; there really isn't another place like this. Q: Where did the name for the store come from? A:The way we came up with the name Transitions was from one of our employees who is a survivor of breast cancer. Women have many transitions they go through in their lives. Some are happy, some are sad. We wanted to help them in the happy times and in the times that they're struggling. Q: How does it work to have products for both new mothers and cancer patients? A: Our theme is hope and inspiration and belief. We have formed a sisterhood. It signals to new mothers that doing those self-breast exams is very important. The women who are going through cancer see that life. They see the babies. With the two combined, it's women helping women. Q: How many people work in the store? A: We have two certified fitters for maternity and oncology. We have an assistant for the office who helps women get pre-authorization for insurance. There are some oncology products you can get reimbursement for. We have five registered nurses who are also lactation consultants that do inpatient and outpatient services. Q: What have you learned from working in the store? A:I'm amazed how strong these women are. They come in here and they want to fight. They want to fight the disease. We have learned a lot from them. I used to work labor and delivery and that was so rewarding and gratifying, but this is just as rewarding. To be in a position to help women who are going through cancer is phenomenal. Q: What would you like to say to women who have been diagnosed with breast cancer? A:What is really important for women to know is that Transitions is a sensitive and professional setting where they can shop with dignity for these personal health care products. We spend time with them. The other thing is we went out shopping. We went to see what the best products were. The products we have to offer are the best out there, and we have variety. Contact the writer: 714-796-6880 or bbernhard@ocregister.com Artificial lymph node transplanted into mice NewScientist.com news service Michael Reilly An artificial lymph node has been transplanted into mice, where it successfully produced immune cells. The new form of bioengineered tissue marks a significant step towards transplanting an entire immune system into patients dying of AIDS, cancer or other diseases, say the researchers who carried out the transplant. Takeshi Watanabe at the RIKEN Institute in Japan and colleagues used a "bioscaffold" made of collagen impregnated with stromal and dendritic cells extracted from the thymus of newborn mice. The entire package – a collagen sponge about 3 to 4 millimetres across – was then implanted into mice with healthy immune systems that had been vaccinated against a harmless antigen (something that triggers an immune response). In a natural lymph node, stromal cells act as "organiser" cells, arranging the various components of the node and aiding its development. Watanabe found that the same was true of the artificial nodes. The implanted stromal cells attracted T and B immune cells (lymphocytes) that were already circulating in the healthy mouse, then organised them into compartments segregated from one another, just as they appear in natural nodes. Empty nodes After the artificial node had filled with antigen-specific T and B cells, Watanabe transplanted it into a mouse with no functioning immune system. The lymphocytes quickly spread out from the artificial node into the animals' own lymph nodes, which lay empty due to the lack of immune activity. When Watanabe injected the same harmless antigen into the immuno-deficient mouse, its transplanted immune system responded vigorously, producing massive numbers of lymphocytes to neutralise the foreign molecule. After a month, these cells’ "memory" was still maintained, and they were able to fight off challenges from the antigen. “It’s one tiny step towards use in humans,” says Watanabe. “The next step is to use human cells in humanised mice. Then, maybe in four or five years, we might be able to make the first prototypes of a human model.” Eventually, Watanabe hopes this technology will provide a revolutionary treatment for patients with AIDS or cancer. By implanting artificial nodes plump with healthy T and B cells in AIDS patients, he believes he might be able to revitalise their damaged immune systems. For cancer, he hopes to adopt a similar approach in which the transplanted nodes will contain T cells trained to hunt down the antigens produced by tumour cells and kill them off. Journal reference: Journal of Clinical Investigation, doi:10.1172/JCI30379 isitor Ratings: Healthcare Professional: General Public: UroToday.com- Lymph node density is a surrogate marker of the extent (i.e. 'quality') of lymph node dissection during radical cystectomy and impacts patient outcome There is a growing body of literature which suggests that the quality of a lymph node dissection radical cystectomy for bladder cancer is a predictor of recurrence-free survival of patients with node positive bladder cancer after cystectomy involvement. However, the 'ideal template' for pelvic node dissections is not standardized and there is a wide variation in extent of dissection. A surrogate marker of quality of node dissection is lymph node density defined as the ratio (percentage) of the number of positive nodes divided by the total number of nodes examined. In the April issue of Journal of Urology, Herr presents data from 5 studies on a total of 979 patients. In 4 studies, higher lymph node density (> 25 or 25%) was a significant predictive factor for survival when adjusted for various patient, tumor and treatment co variables. This remained true even when adjuvant chemotherapy was accounted for, in the one study which examined the same. What is also worth noting from the article is that the range of lymph nodes removed, even in academic centers, can be as few as 1 to as many as 96. Amazingly, data from the SEER registry suggest that, across the country, as many as 40% patients do not undergo a lymph node dissection at all. While the ideal situation would be to have a standardized template which all can agree upon, this is likely to prove difficult to 'regulate'. Lymph node number (and density) is more objective data which can be used to not only risk stratify patients more appropriately, but also serve as a surrogate marker for quality of surgical dissection. Herr HW J Urol. 2007 Apr; 177(4):1273-5 Reviewed by UroToday.com Contributing Editor Ashish M. Kamat, MD UroToday - the only urology website with original content written by global urology key opinion leaders actively engaged in clinical practice. To access the latest urology news releases from UroToday, go to: www.urotoday.com Immune cells known as macrophages linked to growth of lymph vessels in eyes, Medical Studies/Trials Scientists at Schepens Eye Research Institute have discovered that a particular immune cell contributes to the growth of new lymph vessels, which aid in healing. This cell, known as a macrophage, is called in by the body during the wound healing process. The discovery of this new role for the macrophage, published in the September 2005 Journal of Clinical Investigation, may ultimately inspire innovative treatments for blinding eye disease, as well as for other diseases, such as cancer, that rely on the lymph vessels to spread abnormal cells throughout the body. "This is a very significant finding," according to Joan Stein-Streilein, PhD, and Patricia A. D'Amore, PhD, senior authors of the study, Senior Scientists at SERI and members of the Departments of Medicine and Ophthalmology at Harvard Medical School, respectively. "It unlocks a whole new dimension in our understanding of these important cells." The body uses lymph vessels to bring immune cells to an injured organ to carry away debris and fluid to aid healing. Lymph vessels can play a different kind of role in cancer, offering tumor cells a pathway for spreading to other body parts, in a process known as metastasis. Macrophages are large white blood cells called in during wound healing to ingest foreign invaders such as bacteria. They can also present pieces of those intruders to the immune system to jump-start the immune response. Produced in the bone marrow, they can be found in almost all tissues of the body. Unlike many other parts of the body, the clear outer layer of the eye, known as the cornea, does not normally have lymph vessels, except when injury causes lymph vessels to sprout from the edge of the cornea to help heal the wound. Dr. Kazuichi Maruyama, a post-doctoral fellow in D'Amore's and Stein-Streilein's laboratories at SERI, began to suspect a new connection between macrophages and lymph vessels while studying corneal transplants in mice. He became aware of lymph vessels that seemed to be forming "in place," away from those produced at the edge of the cornea. He also noticed that these lymph vessels disappeared after the wounds were healed. Because the cell structure of the new vessels resembled that of macrophages, he began to believe there might be a relationship. In the JCI study, he tested this idea by placing sutures in the corneas of two groups of mice to create injuries that would induce a healing response. Then he gave one group of mice a drug to cause macrophages to commit suicide. When he examined the eyes of both groups, he found those given the drug did not grow as many lymph vessels as the control group without the drug. The implications of this link between macrophages and lymph vessels are far-reaching, according to Stein-Streilein, D'Amore, and Maruyama. D'Amore and Stein-Streilein believe that harnessing this newly found ability of the macrophages could lead to the creation of new drugs or therapies for eye disease. For instance, inducing new "temporary" lymph vessels in retinas could aid in treating diabetic retinopathy by removing fluids leaking from abnormal blood vessels. It is this leaking fluid, characteristic of diabetic retinopathy that can permanently damage the retina and vision. Maruyama speculates that the involvement of macrophages in forming lymph vessels may be universal and may also be involved in spreading cancer. If that were the case, blocking macrophages from helping to grow lymph vessels could inhibit the spread of tumors. The team is now researching the same process in skin wounds and cancer. http://www.eri.harvard.edu/ ------------------------------------------------------------------------ Acroangiodermatitis Marissa Heller MD, Julie K Karen MD, William Fangman MD Dermatology Online Journal 13 (1): 2 New York University Department of Dermatology -------------------------------------------------------------------------------- Abstract A 26-year-old man with a history of chronic primary lymphedema of the left lower extremity presented with elephantiasis, confluent, violaceous, mascerated plaques, and ulcers on the dorsal aspects of the toes of the left foot. Histopathologic examination showed a proliferation of small blood vessels associated with extravasated erythrocytes and hemosiderin deposits consistent with the diagnosis of acroangiodermatitis. Treatment of the focal ulcers includes compression therapy, local wound care, and surgical elimination of the shunt if there is an associated arteriovenous malformation. -------------------------------------------------------------------------------- Clinical synopsis A 26-year-old man was referred to the Charles C. Harris Skin and Cancer Pavilion for the evaluation and treatment of ulcers of the toes of the left foot. There was a remote history of a fractured left leg. Chronic primary lymphedema of the left leg developed three years ago. He subsequently developed a deep venous thrombus in his left leg with a pulmonary embolism that required pulmonary endarterectomy. A filter was placed in the interior vena cava, and he was treated with coumadin. Over the past three years, he noted purple skin lesions and development of ulcers on the toes. Physical examination revealed confluent, violaceous, mascerated plaques with ulcers were present on the dorsal aspects of the toes of the left foot. The dorsal aspect of the foot exhibited verrucous changes. There was 1+ edema of the left foot, and a 1+ dorsalis pedis pulse was noted. The right foot was uninvolved. Figure 3 Histopathology reveals a thick papillary dermis with proliferation of capillaries and venules with plump endothelial cells. There are extravasated erythrocytes and hemosiderin deposition. There is an infiltrate of plasma cells and some lymphocytes. Comment Acroangiodermatitis, a rare condition that is also known as pseudo-Kaposi sarcoma, is a proliferation of the preexisting vasculature. Clinically, it appears as violaceous or brown macules, patches, papules, or plaques on the distal aspects of the lower extremities. It may be unilateral or bilateral and is commonly located over the extensor surfaces, the lateral malleoli, and the dorsal aspects of the feet. Ulcers may develop over the affected areas [1]. Acroangiodermatitis can be associated with venous hypertension, with an arteriovenous malformation, or with an acquired iatrogenic arteriovenous fistula [1, 2]. A variety of other vascular conditions has been reported in association with acroangiodermatitis. These include limb paralysis, vascular damage from amputation or intravenous drug abuse, the thrombophilic 20210A mutation in the prothrombin gene, and Klippel-Trenaunay syndrome [1, 3, 4, 5]. Histopathologic examination shows proliferation of the capillary bed throughout the dermis. Extravasated erythrocytes, fibrosis with spindle cells, and hemosiderin pigment deposition are noted. There may be a superficial, perivascular infiltrate of lymphocytes, macrophages, and eosinophils. Endothelial cells lining the vessels stain with CD34. A differentiating factor between acroangiodermatitis and Kaposi sarcoma is that in the former, the vascular hyperplasia is of preexisting vasculature and in the latter, the vascular hyperplasia is independent of preexisting vasculature [6]. Treatment of acroangiodermatitis involves correction of the underlying vascular pathology. Mainstays of therapy include compression stockings or a compression pump for venous stasis and local wound care for ulcers. In the case of arteriovenous malformations, surgical correction of the shunt can be employed [7]. Medical therapy options are limited. There is one case report of regression of lesions with treatment with oral dapsone 50 mg twice daily for three months in combination with leg elevation and compression [8]. There are case reports of improvement with oral erythromycin in patients with arteriovenous fistulas for hemodialysis [9]. References 1. Rongioletti F, Rebora A. Cutaneous reactive angiomatoses: patterns and classification of reactive vascular proliferation. J Am Acad Dermatol 2003;49:887 2. Samad A, Dodds S. Acroangiodermatitis: review of the literature and report of a case associated with symmetrical foot ulcers. Eur J Vasc Endovasc Surg 2002;24:558 3. Gucluer H, et al. Kaposi-like acroangiodermatitis in an amputee. Br J Dermatol 1999;141:380 4. Martin L, et al. Acroangiodermatitis in a carrier of the thrombophilic 20210A mutation in the prothrombin gene. Br J Dermatol 1999;141:752 5. Lyle WG, Given KS. Acroangiodermatitis (pseudo-Kaposi sarcoma) associated with Klippel- Trenaunay syndrome. Ann Plast Surg 1996;37:654 6. Calonje E, Wilson-Jones E. Vascular tumors: tumors and tumor-like conditions of blood vessels and lymphatics. In: Elder D, et al, eds. Lever's Histopathology of the Skin. 8th ed. Philadelphia: Lippincott- Raven, 1997:914 7. Pires A, et al. Effect of compression therapy on a pseudo-Kaposi sarcoma. Dermatology 1999;198: 439 8. Rashkovsky I, et al. Acro-angiodermatitis: review of the literature and report of a case. Acta Derm Venereol (Stockh) 1995;75:475 9. Kim TH, et al. Pseudo-Kaposi's sarcoma associated with acquired arteriovenous fistula. J Dermatol 1997;24:28 --------------------------------- Survivor seizes chance to make people aware Mark Goldstein, 74, developed, overcame bout of breast cancer BY DAVE BENJAMIN Staff Writer Mark Goldstein JACKSON - He is a survivor and his aim is to heighten the awareness that men can develop breast cancer. "Statistically, this is a woman's disease and there is no doubt about that" said Mark Goldstein, 74, a 19- year survivor male breast cancer. Goldstein, who lives in northern New Jersey, spoke to the Men's Club at the Westlake Golf and Country Club adult community on Sept. 20. "There are about 185,000 women diagnosed with breast cancer each year, compared to 2,030 men who are diagnosed yearly, but it's just as tragic for a man lose his life to this form of the disease as it is for a woman to lose her life," he said. Goldstein said many men cannot believe they can develop what is thought as a woman's disease, "If you don't think that is shocking then all you would have to do is to have been in my shoes at that time when everybody around me expressed, some seriously and some with a wink, that 'Mark got what women get,' " he said. Before that, Goldstein said, he did not have a clue that men could develop breast cancer. That all changed in 1988. Goldstein said one day in February 1988 he was shaving when he looked in the mirror and noticed that his left nipple was receding and beneath it he could feel a lump. In typical male fashion he did nothing. "Had that been my wife, we would have been in the doctor's office the next day, but for me there was not only no reaction, there was inaction," he said. "I did nothing for three months." He said about 2,000 men are diagnosed with breast cancer every year and about 450 succumb to the disease. That number is increasing, he said. "But you can't find (male) breast cancer listed under the 15 conventional cancers," he said. "There's prostate, colon, bladder, melanoma, lymphoma and on and on. We're off the radar in terms of awareness." He told his audience that if breast cancer was a sport, men would know all about it. "We would have all the statistics on it," he said. "We would chart it. We would socialize about it and it would probably have a uniform, but it's not a sport." Goldstein said embarrassment, fear and denial all play a role in the delay of seeking help. He said the public and insurance companies must be educated on the subject. "I submitted a claim to my wife's company and it came back with a note that said the service that has been billed cannot be performed on a person of this sex," Goldstein said. "I called them up and I didn't have to say much, just the word 'sue.' " Goldstein underwent treatment for the disease - chemotherapy, radiation and a modified radical mastectomy - and from 1988 and 1992, "I lived a relatively normal post-breast cancer life," he said. "I did my job. I engaged in activities that I had done before and about halfway through [that period of time] I felt I transitioned from being a survivor to being a conqueror. Then one day in September 1992 I felt I reached a transition [again] from a survivor and conqueror to becoming an advocate." Goldstein said he heard about a race in New York City and knew he had to participate in the "For Women Only Race for the Cure." He filled out the race application using only his first initial and paid the entry fee with a money order. On race day he appeared at the starting line. "This was the start of my advocacy," he told the audience. "When I presented myself they said I couldn't run because I was a man," but that did not stop Goldstein and off he went. Goldstein said there are different kinds of tragedies and said they typically happen to somebody else. "When these tragedies occur there is a response," he said. "People who see these tragedies say, 'Thank God it wasn't me.' " Goldstein said there are also personal tragedies where people ask "Why me?" Those individuals focus on questions like "What did I do to bring this to myself?" "What could I have done to stop it from happening?" and "What should I do about what's happened to me?" It is the "see and seize" group that converges with the "what should I do?" people from the "why me?" group who act. "From that comes the 'why not me?' group who says they can do something and the most perfect symbol of this is Nancy Brinker, who in 1982 made a pledge to her dying sister Susan (Komen) that she would do everything she could to eradicate breast cancer," Goldstein said. "That was the start of the Susan G. Komen Breast Cancer Foundation, the foundation we support here at Westlake." Goldstein said that in their response to breast cancer, women have started foundations, initiated crusades, designated awareness months, formed networks, lobbied public officials, walked, run and marched. "Twenty years ago breast cancer was a closeted subject and no one spoke about it," he said, "but the Komen Race for the Cure has turned that around." Goldstein said he has run in every Susan G. Komen Race for the Cure, and others, for a total of 167 races throughout the United States and internationally. In 2005 he was inducted into the National Distance Running Hall of Fame "I am fortunate to have the endorsement by way of sponsorship of the New Balance Athletic Shoe Company. I am a member of the honorary Team New Balance which is a team of survivors and I'm the only male survivor on that team." Goldstein, said he participates in the Race for the Cure to dispel the misconception that breast cancer is only a women's disease. Goldstein said he appreciates what the Westlake Men's Club has done in its support of the Race for the Cure, Goldstein said he lives with lymphedema, which is the byproduct of excessive lymph removal that occurred during the modified radical mastectomy he underwent 19 years ago. Lymphedema is incurable. Men's Club Vice President Larry Hartman said the organization is 6 years old. Between 80 and 100 men attend monthly meetings. The club sponsors a Little League baseball team, provides scholarships to Jackson high school students, raises funds to send phone cards to New Jersey soldiers who are serving in Iraq and Afghanistan, helps fund the Race for the Cure and supports research into prostate cancer and autism. Living Columnist Kathy Kemp Miss Ezell: A treasure and friend One spring day in 1990, I decided to help a little old lady fix her roof. It was ancient and leaking, Nora Ezell told me. She had been up there, hammering shingles, the day I stopped by to interview her for a story about her quilts. I'd already seen pictures of her colorful bed covers. Some of her designs- such as the "wedding ring" and the "friendship chain" - had been passed through generations. It was her "story" quilts, whose panels often celebrated the accomplishments of black Americans, that were attracting folklorists and art dealers. (See them in the Alabama Folk Art exhibit in the Young & Vann building, 1731 First Ave. North, through December). "Miss Ezell," as I came to call her, quit hammering long enough to tell me her life's story: One of 10 children, she was born in Mississippi and grew up west of Birmingham. Her father farmed and her mother quilted. Young Nora dropped out of school, married, divorced, married again, worked in a garment factory, underwent a double mastectomy and beat cancer, only to lose her only child, Annie Ruth, to the same disease. Miss Ezell took up quilting in the 1980s to entertain her sick daughter. She told me this, and much more, during my visit to her modest frame house, in the tiny Greene County town of Mantua. She was then 72 and suffering from lymphedema, which caused her arm to swell. I was decades younger and physically fit. So when Miss Ezell told me of her roof problems, I offered to help. Never mind my fear of heights, or the fact that my construction skills mostly involved nailing picture hangers to the wall. The following Saturday, a friend and I drove to Mantua and found Miss Ezell in her backyard, a ladder propped against the house. A roll of tar paper lay on the grass. "Let us do that," I told her as I grabbed one end of the roll and my friend the other. It must have weighed 75 pounds. We couldn't budge it. Miss Ezell eyed us with disdain. Something she had told me in our interview kept ringing in my ears: "I cannot stand stupid people." She stepped past us, lifted that roll to her shoulder and climbed the ladder to the roof. "Y'all coming?" she asked. By then we were all giggling. "Watch what your mama does," Miss Ezell said as she tarred and nailed down the roofing paper. Needless to say, she did all the work. My friend didn't have much of a clue, and I sat on the ridge, too terrified to move. Even so, I got covered in tar. Miss Ezell loaned me a muumuu to wear on the ride home. We'd had such fun that I returned to "help" her with other home repairs. Or I'd see her at art shows, where she regularly introduced me as her daughter. Miss Ezell died of a stroke earlier this month at age 88. Around the world, various obituaries noted that her quilts have hung in the Smithsonian Institution and in New York's American Folk Art Museum, and that she won a National Heritage Fellowship in 1992. There are plenty of folks like me, in Alabama and beyond, who also admired her spirit and benefited from her kindness and wisdom. She was a national treasure, in more ways than one. E-mail kkemp@bhamnews.com. ------------------------------------------------------- Hereditary Breast Cancer Linked to new Cancers (Ivanhoe Newswire) -- The risk for a new cancer in the unaffected breast substantially increases in women diagnosed with unilateral, hereditary breast cancer, according to a recent study. The study, led by Katarina Shahedi, M.D., of the Umeå University and the Karolinska Institute in Stockholm, Sweden, reveals women younger than 50 diagnosed with hereditary (non-BRCA) breast cancer are at a significantly higher risk for developing cancer in the other breast, all known as contralateral breast cancer (CBC). Researchers reviewed data from 120 families and 204 women with unilateral breast cancer and a family history of breast cancer but no BRCA mutations to better characterize the CBC risk for the women. They found the long-term CBC risk is significantly higher in women with hereditary breast cancer compared to the risk of developing a primary breast cancer in the general population. Women taking adjuvant hormonal therapy, however, had a significantly lower risk for CBC compared to those not taking it. According to study authors, adjuvant chemotherapy had no apparent effect on risk. Study authors say the impact of these results is most apparent for premenopausal women, as one in five will develop CBC after only 10 years. It is therefore important to consider and provide information about the risk of CBC to women with unilateral breast cancer or a family history of breast cancer. SOURCE: CANCER, published online Feb. 13, 2006 Doctor Shortage NEW YORK (Ivanhoe Broadcast News) --- You could be waiting weeks or months for a doctor’s appointment, traveling further to get there and spending less time with your doc when you do … that’s if you get to even see a physician! The reason -- experts say we’re headed for a doctor shortage in this country. Eight months into a high risk pregnancy and Barbara Chorzempa was doing well. But one obstacle stood between her and the birth of her baby -- a grueling drive up and over this mountain -- with its hairpin turns and steep cliffs. “I was very nervous about having to make that trip. I was worried about the jolting of the car. Definitely scared,” says Chorzempa. There was no way around it. Chorzempa couldn’t deliver in the rural town she lives. There’s no hospital with a maternity ward and not a single obstetrician for miles. “It’s a scary thought, not being close to a hospital and not having a doctor close.” But it’s a thought Americans everywhere may have to get used to. Rising malpractice premiums, falling reimbursement and fears of being sued have forced obstetricians in some states into early retirement. It’s creating a shortage in this specialty. In fact, 1,500 counties in the United States do not even have a single obstetrician. Patrick Vetere, M.D., used to deliver babies. He now just practices gynecology. “We have a medical liability system that’s out of control. I felt not doing obstetrics, you could avoid quite a bit of that,” Dr. Vetere, who practices in Garden City, N.Y., says. But the shortage won’t be limited to obstetricians. As 79 million baby boomers reach old age, experts predict we’ll be short 200,000 physicians by the year 2020. “Any disaster that calls forth the need for lots of doctors, they just aren’t there,” says Richard Cooper, M.D., with the Council of Physician and Nurse Supply and the University of Pennsylvania. That’s because in the mid 90s, congress capped spending on medical residencies, the key on-the-job training program that all doctors need before they are allowed to practice. And only three medical schools have opened since 1982. Now, older physicians are retiring in large numbers, and younger doctors, many of them women with children, are demanding shorter workweeks. “Even this newer generation of men, male physicians tend to want to be more involved with their families, tend to want to work fewer nights, fewer weekends,” says Dr. Cooper. The trend is causing emergency rooms across the country to scramble to get doctors to cover shifts, especially overnight. In geriatrics, the shortage is also acute. There are 7,600 in practice, while some estimate need 20,000 to meet our need. That’s forcing seniors, like Henry Fischel, to live with his pain. “It took me over three years to find the medical help that I needed,” says Fischel. “It’s a very significant problem, especially because you have an enormous aging population,” says Beatriz Korc-Grodzicki, M.D., Ph.D., an assistant professor of geriatric medicine at Mount Sinai School of Medicine in New York. Other specialties that will suffer: Oncology -- the demand is projected to increase by 48 percent because of more cancer survivors, but supply is only projected to increase by 14 percent. Experts predict a 20- percent decrease in the number of cardiologists by 2020. And one report suggests the United States should have more than 30,000 child psychiatrists, but there are less than 7,000 in practice right now. For patients like Chorzempa, help was on the other side of the mountain. At eight months pregnant, she moved to a friend’s basement to be closer to her doctor and avoid that treacherous ride. She’s now got a healthy baby girl. Experts say we’ll need to train 10,000 more physicians each year to meet our needs. Medical schools are considering slightly increasing enrollment, but there’s no quick fix. It takes about seven years to train new doctors. And congress has not yet approved enough spending to add to the number of residency positions. For more information, please contact: Richard A. Cooper, M.D. Professor of Medicine and Senior Fellow Leonard Davis Institute of Health Economics University of Pennsylvania 3641 Locust Walk Philadelphia, PA 19104 Doctors for Sale NEW YORK (Ivanhoe Broadcast News) -- Robert Goodman, M.D., usually spends his lunch hour alone. He doesn’t want drug reps to treat him to free meals in exchange for a Noon-time sales pitch. “When we receive a gift, even a small gift, we have a very strong need to reciprocate,” says Dr. Goodman, an internist at Montefiore Medical Center in New York. Some argue doctors may be choosing your drugs, not on the basis of the best medicine, but the best marketing. “Reps come up to them and say, 'hey doc, what’s the deal? We’ve been going out to dinner and you’re not prescribing my product,'” says Dr. Goodman. Pharmaceutical companies offer physicians free meals to the tune of 4 million dollars a day. It’s all part of a staggering 12 billion dollars they spend each year marketing directly to doctors. “If you have to know what drug companies are about, you need to know three things: marketing, marketing, marketing,” says David Rothman, Ph.D., with The Prescription Project. Every day, as many as 100,000 drug reps, called detailers, fan out across the country. Each one meets with as many as eight doctors a day. “I was not compensated for helping doctors help patients, I was compensated for getting the doctors in my territory to write more of my particular pills,” says Kathleen Slattery-Moschkau, a former detailer. She says she and most of her colleagues were never trained in medicine. “Most of us had no business talking to doctors about these drugs that could mean the difference between, sometimes mean the difference between life and death,” she says. The reps are armed with sophisticated information. Using a technique called data-mining, the pharmaceutical companies provide the sales reps with weekly records on exactly what brand of drugs and in what amount each doctor is prescribing. “So the sales rep goes in, he or she talks to the doctor, pushes a certain product, then the next week, they’ll look at the prescribing and see if it worked,” explains Susan Chimonas, Ph.D., with The Prescription Project. The companies counter they play a role in educating doctors about the new medications. Some doctors say it's information they want. “We’re busy in our practice. It’s hard to keep up with the most up to date literature, so at times, it’s helpful,” says Heather Fullerton, M.D., a pediatric neurovascular specialist at the University of California, San Francisco. And what about those free samples? “The samples can really help patients who are financially disadvantaged. They don’t have health insurance,” says Katrina Bramstedt, a clinical ethicist at California Pacific Medical Center in San Francisco. She says considering the patient's need is paramount. “Patients come first, before making money, before aging, before fame. That’s why we go into medicine is to help our patients,” says Bramstedt. Doctors can access unbiased information about medication on the Internet, so depending on the pharmaceutical companies is not necessary. “Information on costs, side effects, interactions with other drugs, place and therapy information that, let's face it, a salesperson is not likely to give you,” says Dr. Goodman. Dr. Rothman says more needs to be done. “Keep the drug reps out of doctors’ offices. Abolish gifts. Abolish samples,” he says. These are changes he says could be a prescription for better health care. For more information, please contact: The Prescription Project 30 Winter Street Boston, MA 02108 (617) 275-2853 Institute on Medicine as a Profession Columbia College of Physicians & Surgeons 630 W, 168th Street Box 11 NY, NY 10032 (212)305-4184 Stress Increases Skin Infections (Ivanhoe Newswire) -- You know stress can affect your health as it weakens the immune system, but how exactly does it happen? New research from the University of California, San Francisco finds a mechanical link in mice between psychological stress and the increased risk of skin infections. The study shows mice put in conditions of psychological stress are more susceptible to group A Streptococcus skin infections than normal mice. Researchers say psychological stress disrupts the skin’s antimicrobial barrier – essentially stressed-out skin loses its antimicrobial defense mechanism. Results also show stress increased the production of glucocorticoids which blocked the synthesis of fats in the epidermis of the skin. These findings suggest the immune function of the skin may be improved in stressed-out people by inhibiting the action of glucocorticoids. SOURCE: The Journal of Clinical Investigation, 2007;117:3339-49 Related Articles in Archives:Precision Dynamics Corporation Offers Color Coded Alert Band Wristbands for Patient Safety SAN FERNANDO, Calif.--(BUSINESS WIRE)--Precision Dynamics Corporation (PDC), a leader and innovator of automated wristband identification, announces the release of color coded Alert Band Wristbands for patient safety. Throughout the United States, healthcare facilities have long used color-coded wristbands to signal important medical information. In fact, according to the 2005 Patient Safety Authority Survey of Pennsylvania Hospitals four out of five respondents’ facilities used color-coded patient wristbands. However, the lack of consistency in wristband meanings and how they are applied presents problems when patients are transferred among facilities and when patients are cared for by clinicians in multiple hospitals. This challenge was highlighted when a patient was nearly not resuscitated during a cardiopulmonary arrest because she was incorrectly designated “DNR” with a color-coded wristband by a nurse who worked in multiple facilities and was confused about the meanings of different colors.(a) Events such as these increase the risks of making potentially fatal patient errors. Precision Dynamics’ color coded Alert Band wristbands greatly minimize the chance of error by providing pre-printed, large visible text/cues and an extensive range of vibrant colors that allow healthcare workers to immediately identify patient medical conditions. Each band is equipped with PDC’s patented SecurSnap® closure for optimum patient comfort and safety. While at this time there isn’t a national standard assigning specific color wristbands to specific alerts, individual states such as Arizona, New York, Pennsylvania, Ohio and others are adopting standards, and PDC supports these and all patient safety initiatives. In support of these initiatives, PDC’s Color Coded Alert Bands provide maximum patient protection and comfort in one total wristband solution. PDC’s Color Coded Alert Wristbands provides healthcare professionals with the following advantages: Clear Visibility of patient alerts even if the patient shifts or the patient cannot be disturbed. SecurSnap® closures for patient security, safety and comfort. Flexibility in size for patient comfort. Custom printed text to fit any standardized level now and in the future. Custom alert logos to allow for less common conditions such as “Limb alert” or “Lymphedema Alert” etc. Latex-free. For more information on PDC’s color Alert Bands, please visit call 800-772-1122. For media inquiries and requests for hi-resolution product photos, please contact: Adrienne S. Lamm at 818-897-1111 ext. 1330 or adrienne@pdcorp.com. About Precision Dynamics With over 50 years of experience, PDC is a global leader and pacesetter in the development of Auto ID wristband systems for healthcare, leisure and entertainment, and law enforcement. The company introduced the first patient Bar Code ID Wristband, patented Smart Band® Radio Frequency Identification (RFID) Wristbands, the AgeBand® Age/ID System, and PDC Smart Kiosk® Cashless RFID System. PDC is committed to 100% quality in service, design, and manufacturing and has ISO- 9001: 2000 and ISO-13485: 2003 certification. For more information, visit www.pdcorp.com. Precision Dynamics Corporation name and logo, Securline®, SecurSnap®, Smart Band®, AgeBand®, and PDC Smart Kiosk® are registered trademarks of Precision Dynamics Corporation. All other product names, company names, marks, logos and symbols mentioned herein are trademarks of their respective owners. A surgeon at the University of Arkansas for Medical Sciences (UAMS) has developed a new procedure to prevent one of the most common side effects associated with breast cancer treatment lymphedema or swelling of the arms due to faulty drainage of the lymph nodes. V. Suzanne Klimberg, M.D., director of the UAMS breast cancer program, led a study funded by the Tenenbaum Breast Cancer Research Foundation of breast cancer patients at risk for developing lymphedema. Her findings were published in the February issue of the Annals of Surgical Oncology, and she will present the study March 17 at the Society of Surgical Oncology 60th Annual Cancer Symposium in Washington, D.C. "The removal and analysis of the lymph nodes under the arm remains the most important factor in determining the severity of disease in breast cancer patients," Klimberg said. "In the past, surgery to remove the lymph nodes and most of the fat and tissue in the armpit often resulted in complications, including lymphedema." Five percent to 50 percent of women undergoing surgical treatment for breast cancer have developed lymphedema, mainly dependent upon the extent of surgery. At the ACRC, surgeons determined that the draining of the first lymph node, known as the sentinel lymph node, is capable of predicting if the cancer has spread to the remaining armpit lymph nodes, known as axillary lymph nodes. This is a less invasive surgery and reduces the likelihood of complications. However, the lymph node system is at risk of disruption during either a sentinel lymph node biopsy or an axillary lymph node dissection, which often leads to swelling in the arm. To prevent the arm swelling, Klimberg has developed the Axillary Reverse Mapping (ARM) procedure. The new technique evaluates the ways in which fluid drains through the lymph node system in the arm through the injection of blue dye. The dye is used to map the drainage of the arm. "Mapping the drainage of the arm decreases the chances of unintended disruption of the lymph node system during surgery and reduces the risk of developing swelling in the arm," Klimberg said. "We are the first to study lymph node drainage in the arm and are now using the ARM procedure as standard procedure at UAMS." Klimberg will soon begin conducting training seminars on the procedure throughout the country. The seminars will be sponsored by the global medical device company Ethicon, a branch of Johnson & Johnson. Klimberg is chief of the Division of Breast Surgical Oncology at UAMS and a professor in the Departments of Surgery and Pathology. She also is director of the Breast Cancer Program at the UAMS' Arkansas Cancer Research Center as well as director of Breast Fellowship in Diseases of the Breast at UAMS. Additional UAMS staff members involved in the published study are Kent Westbrook, M.D.; distinguished professor; Ronda Henry-Tillman, M.D., associate professor of surgery; Margaret Thompson, fellow; Soheila Korourian, M.D., associate professor of pathology; Keiva Bland, fellow; K. Jackman, surgery resident; and Laura Adkins, data manager. UAMS is the state's only comprehensive academic health center, with five colleges, a graduate school, a medical center, six centers of excellence and a statewide network of regional centers. UAMS has about 2,430 students and 715 medical residents. It is one of the state's largest public employers with about 9,400 employees, including nearly 1,000 physicians who provide medical care to patients at UAMS, Arkansas Children's Hospital, the VA Medical Center and UAMS' Area Health Education Centers throughout the state. UAMS and its affiliates have an economic impact in Arkansas of $5 billion a year. For more information, visit http://www.uams.edu/. University of Arkansas for Medical Sciences 4301 W. Markham St., Slot 716 Little Rock, AR 72205 United States http://www.uams.edu/ -------------------------------------------------------------- Lymphatic vessel and lymph node function are restored with growth factor treatment Medical Research News Published: Tuesday, 4-Dec-2007 The frequent spread of certain cancers to lymph nodes often necessitates surgery or radiation therapy that damages the lymphatic system and can cause lymphedema, a condition of localized fluid retention that often increases susceptibility to infections. The researchers of the University of Helsinki, Finland, and the Ludwig Institute of Cancer Research show that application of vascular endothelial growth factor-C (VEGF-C) to replace excised mouse lymph nodes and lymph vessels ensures formation of mature lymphatic vessels and incorporation of lymph node transplants into existing lymphatic vasculature. An improved outcome of lymph node transplantation is evidenced by improved lymphatic drainage and restoration of normal lymphatic vascular anatomy in VEGF-C-treated mice. The ability to transfer lymph nodes that reconstitute a functional network of lymphatic vessels in adult tissues is of particular importance in cancer follow-up therapy, as lymph nodes can prevent systemic dissemination of metastases. Accordingly, VEGF-C-treated lymph nodes were more effective in trapping metastatic tumor cells than control transplants. It has been estimated that approximately 20-30% of patients that have undergone irradiation or surgery of the armpit in response to lymph node metastases develop lymphedema later on. Damage to the large collecting lymphatic vessels, which resemble smaller veins, causes the vast majority of all lymphedemas. It has been estimated that several million patients suffer from such acquired lymphedema worldwide. The treatment of lymphedema is currently based on physiotherapy, compression garments and occasionally surgery, but means to reconstitute the collecting lymphatic vessels and cure the condition are limited. The Finnish researchers applied vascular endothelial growth factor-C (VEGF-C) gene therapy in mice after surgery removal of axillary lymph nodes, a procedure that mimicked removal of axillary lymph nodes in patients in response to metastatic breast cancer. They found that treatment of lymph node- excised mice with adenoviral VEGF-C gene transfer vectors induced robust growth of the lymphatic capillaries, which gradually underwent an intrinsic remodeling, differentiation and maturation program into functional collecting lymphatic vessels, including formation of uniform endothelial cell-cell junctions and intraluminal valves. As VEGF-C quite potently increases the rate of lymph node metastasis, the researchers sought to develop a mode of therapy that could be safely applied also in patients that had been treated for cancer. They established that the VEGF-C therapy greatly improved the outcome of lymph node transplantation. As a result, they were able to reconstruct the normal gross anatomy of the lymphatic network in the axilla, including both the lymphatic vessels and the nodes, suggesting that VEGF-C therapy combined to autologous lymph node transfer is feasible in the clinical setting. The advantage of this rationale is increased patient safety in instances of recurrent malignancies, as the transplanted lymph nodes provide an immunological barrier against systemic dissemination of cancer cells, as well as other pathogens. The findings demonstrate for the first time that growth factor therapy can be used to generate functional and mature collecting lymphatic vessels. This, combined with lymph node transplantation, allows for complete restoration of the lymphatic system in damaged tissues, and provides a working model for future treatment of lymphedema in patients. Effective lymph node transplantation holds tremendous potential for immunotherapy applications in the treatment of diseases such as cancer and chronic infections. Furthermore, the findings encourage the use of growth factor therapy to enhance the vascular integration and viability of transplanted tissues. The group is currently pursuing this form of therapy in larger animal models in order to eventually treat lymphedema patients. Further the group aims to discover methods that would accelerate lymphatic vessel maturation. http://www.helsinki.fi/ Effect of lymphedema on the recovery of fractures. Arslan H, Uludað A, Kapukaya A, Gezici A, Bekler HI, Ketani A. Department of Orthopedic and Trauma Surgery, University of Dicle, School of Medicine, Diyarbakir, Turkey. BACKGROUND: Lymphedema delays the healing of any wound by negatively affecting its inflammatory period. Whether it affects bone healing in a similar negative manner is unknown. Therefore, we experimentally investigated the effect of lymphedema on fracture recovery. METHODS: We used thirty 200- to 250-g Sprague-Dawley rats for the experiment. The rats were randomly divided into two groups of 15 rats each for the experimental lymphedema and control groups. Lymphedema development was confirmed by measuring the circumference and diameter of the extremities together with lymphoscintigraphy. Twenty days after the development of lymphedema, a fracture model was created in both groups in the right tibia with mid-diaphyseal osteotomy and fixing with an intramedullary Kirschner wire. After 6 weeks, all rats were sacrificed and the callus tissue that formed along the osteotomy was compared between groups with respect to radiographic, histological, and biomechanical characteristics. RESULTS: The three-point bending test yielded an average stiffness value of 1227 N/mm (n = 6) in the control group and 284 N/mm (n = 7) in the experimental lymphedema group (P < 0.05). At the end of week 6, radiographic evaluation showed that solid knitting was obtained in the control group, whereas in the lymphedema group delayed or no knitting was observed. In the control group, histological investigation revealed normal callus morphology. Trabecular bone was normal and osteoblast and osteoclast activity was clearly evident. The bone was stained homogeneously with hematoxylin and eosin, and ossification was within normal limits. In the lymphedema group, however, the histological appearance was mostly that of scar tissue. In addition, osteoblast and osteoclast activity was much less visible or absent. CONCLUSIONS: Lymphedema negatively affected bone healing in rats. However, the mechanism of this negative effect and its occurrence in humans are still unknown. Further experimental and clinical studies are needed to support and extend our findings. PMID: 18040641 [PubMed - as supplied by publisher] HEALTH & SCIENCE Lymphedema no longer rare, still underdiagnosed Climbing rates of obesity may be adding to the burdens of the lymphatic system and boosting the number of cases of lymphedema. By Susan J. Landers, AMNews staff. Dec. 3, 2007. Washington -- Trained in family practice medicine, Caroline Fife, MD, didn't know what she was getting into when she decided to begin treating people with lymphedema. She was operating a wound clinic at Memorial Hermann-Texas Medical Center in Houston and was receiving calls from people seeking relief for their swollen limbs. They seemed to have nowhere else to go. So she thought, "How hard can it be? I know a lot about leg swelling." "Never say that," she cautioned. About nine years ago, she hired a part-time therapist for the clinic. Within a year she had eight therapists. "Patients came out of the woodwork." She's been treating patients with lymphedema ever since, and she's had to reach out to others to learn how best to do so. "I had one lecture on the lymphatic system in medical school. [Lymphedema] seemed so rare I thought I would never need to know about it." "It's an ignored field of medicine," said Saskia Thiadens, RN, the executive director of the National Lymphedema Network, based in Oakland, Calif., which she founded 20 years ago. "I would say that of the majority of patients who go to see their primary care physicians, the chances that he or she will be diagnosed are pretty slim." Many patients are misdiagnosed for years, said Andrea Cheville, MD, associate professor of physical medicine and rehabilitation at the Mayo Clinic in Rochester, Minn. When diagnosing a patient with a swollen leg, for example, physicians tend to think, "Is it the heart? Is there a blood clot? Is there a tumor in the abdomen? Often patients get an echocardiogram. They will get an ultrasound of their leg and a CT scan of the belly. If those are negative, many times they are told, 'Well, this is nothing that is going to kill you. Aren't you glad? Good-bye.' " Women treated for breast cancer have a greater chance of having lymphedema than does the general population. Yet it's not so unusual to see patients, both men and women, with swollen limbs caused by a slowdown in the lymphatic system, which serves as an extensive drainage network to maintain the proper body fluid levels and defend against infections. The numbers of people affected by the condition are difficult to come by. Estimates range from 35% to 45% of women treated for breast cancer -- a large number in itself considering that about 2.4 million women alive today have had breast cancer, according to the Centers for Disease Control and Prevention. This population is more commonly affected, since lymph nodes may be removed during treatment, thus slowing the entire system. The lymphedema network has had a patient questionnaire on its Web site since 2001. Respondents are about equally divided as to whether they have primary lymphedema, which is congenital; or secondary, which seems to be due to a trauma, such as surgery. But even that distinction has blurred as researchers are beginning to understand that everyone's lymph system is not created equal, Dr. Fife said. One person may have a fantastic drainage system that can continue to function well despite a huge assault, such as a radical mastectomy. Another person's system may be less robust and be disrupted by a minor injury. Regardless, any slowdown can lead to the pooling of lymph and its cargo of protein molecules, salts, glucose, urea and other substances. The system carries several liters of fluid a day. An obstruction could result in tremendous amounts of fluid building in the body. Another consequence of obesity The rise in obesity is also contributing to the numbers of lymphedema patients. Ten years ago Dr. Fife didn't have any patients who weighed 500 pounds. Now, 2% or more of her patients are at this weight or heavier. Why morbid obesity leads to lymphedema is unknown, but one theory is that fat may block the system. "So as everyone gets fatter, we have more lymphedema," Dr. Fife said. Morbid obesity is a contributing factor to development of lymphedema. Once a swelling has occurred, avoiding any stress on that body part is essential for preventing recurrences. Patients who have had lymphedema should not have a blood pressure cuff wrapped around the affected limb, or have injections or blood draws, Thiadens said. Go to the opposite arm or the leg. Although there is no cure, controlling the swelling is important. Swelling can become permanent and cause irreversible limb distortions. In addition, other skin conditions can develop, including cellulitis. Plus, the body's defenses are impaired. One of Dr. Fife's patients, for instance, reads meters for the gas company. While tramping through backyards all day, he is bitten by mosquitoes and fire ants, and those bites often lead to infections and hospitalizations. Treatment for lymphedema is a gentle massaging technique, called manual lymphatic drainage, which encourages lymph flow. Once a limb is reduced to near-normal size, efforts switch to compression bandages and garments to keep the swelling down. Although lymph flow maps, complete with roadblocks, have not been available for years -- an earlier mapping technique had been painful and dangerous and was abandoned -- promising research is under way at Baylor College of Medicine, Houston. Fluorescent dye is injected just under the skin, picked up by the lymphatics and transported throughout the system, said Eva M. Sevick-Muraca, PhD, professor of radiology at Baylor and principal investigator for the study. Its path is illuminated by shining near-infrared light on the skin. The light can penetrate several centimeters of tissue. The technique, developed with funds from the American Cancer Society and the National Institutes of Health, has been tested in a phase I trial with normal subjects because, "We don't even know what normal lymph flow looks like," Dr. Sevick-Muraca said. Researchers are beginning to test the system on lymphedema patients, specifically attempting to determine if lymph flow is enhanced by massage. "We image before, during and after the massage and see if the lymph is being pushed into the correct nodal basin," she said. A new drug target for preventing lymphedema disease has been discovered by a team of researchers, according to a new study published recently in the prestigious medical Journal of Clinical Investigation. The study has established that a previously known hormone secreted by all body cells and related to cardiovascular disease, may be critical in the development of the lymphedema cancer disease. The idea is, according to the new study, to target this hormone, called adrenomedullin. The lymphedema cancer disease is a potentially severe disease that causes painful swelling in arms and legs. Experts estimate that the lymphedema disease affects more than 1000 million people worldwide. Kathleen M. Caron, PhD., from the Department of Cell and Molecular Physiology and The Department of Genetics, The University of North Carolina, Chapel Hill, NC. (USA), led the study along with colleagues from both departments at UNC. They believe, according to the study, that have discovered the basis for therapies that will prevent cancer cells to travel through the lymph system preventing then the spreading of the cancer to other parts of the human body. The hormone Adrenomedullin is involved in a variety of human body functions. For example it is responsible for regulating blood vessel opening and promote the growth of new blood vessels. It helps control metabolism, antibacterial issues and nerve signaling. Caron and colleagues have discovered a new function for adrenomodullin. This small peptide is related to the normal development of the lymphatic system, which is an relevant part of the human body's immune system. The lymphatic system is formed by a myriad of tiny-networked tubes and nodes that transport a fluid called lymph. These tubes resemble blood vessels and run throughout the human body. Its function is catch up immune cells that have leach out from cells and get them back were they belong. Caron and her team of colleagues took mice and genetically manipulated until they lacked completely of adrenomodullin. In these mice the developed lymphangiogenesis, that is the swelling on the lymph nodes, known to cause lymphedema. The only treatment available today for lymphedema is to using low-compression stockings and garments, and massage. But these are not of too much help. In this new study researchers have described three new targets, adrenomedullin and two of its partners in the cell, which could offer hope for lymphedema sufferers since they could be the basis for the pharmaceutical treatment for lymphedema. The authors believe that by increasing adrenomedullin, the lymph sacs will proliferate and take up more fluid. This could be the basis for a new treatment for lymphedema and also be helpful preventing the spread of cancer since cancers spreads sometimes through the lymphatic system Source: Caron et al. . 2007. Adrenomedullin signaling is necessary for murine lymphatic vascular de HEALTH & SCIENCE Lymphedema no longer rare, still underdiagnosed Climbing rates of obesity may be adding to the burdens of the lymphatic system and boosting the number of cases of lymphedema. By Susan J. Landers, AMNews staff. Dec. 3, 2007. -------------------------------------------------------------------------------- Washington -- Trained in family practice medicine, Caroline Fife, MD, didn't know what she was getting into when she decided to begin treating people with lymphedema. She was operating a wound clinic at Memorial Hermann-Texas Medical Center in Houston and was receiving calls from people seeking relief for their swollen limbs. They seemed to have nowhere else to go. So she thought, "How hard can it be? I know a lot about leg swelling." "Never say that," she cautioned. About nine years ago, she hired a part-time therapist for the clinic. Within a year she had eight therapists. "Patients came out of the woodwork." She's been treating patients with lymphedema ever since, and she's had to reach out to others to learn how best to do so. "I had one lecture on the lymphatic system in medical school. [Lymphedema] seemed so rare I thought I would never need to know about it." "It's an ignored field of medicine," said Saskia Thiadens, RN, the executive director of the National Lymphedema Network, based in Oakland, Calif., which she founded 20 years ago. "I would say that of the majority of patients who go to see their primary care physicians, the chances that he or she will be diagnosed are pretty slim." Many patients are misdiagnosed for years, said Andrea Cheville, MD, associate professor of physical medicine and rehabilitation at the Mayo Clinic in Rochester, Minn. When diagnosing a patient with a swollen leg, for example, physicians tend to think, "Is it the heart? Is there a blood clot? Is there a tumor in the abdomen? Often patients get an echocardiogram. They will get an ultrasound of their leg and a CT scan of the belly. If those are negative, many times they are told, 'Well, this is nothing that is going to kill you. Aren't you glad? Good-bye.' " Women treated for breast cancer have a greater chance of having lymphedema than does the general population. Yet it's not so unusual to see patients, both men and women, with swollen limbs caused by a slowdown in the lymphatic system, which serves as an extensive drainage network to maintain the proper body fluid levels and defend against infections. The numbers of people affected by the condition are difficult to come by. Estimates range from 35% to 45% of women treated for breast cancer -- a large number in itself considering that about 2.4 million women alive today have had breast cancer, according to the Centers for Disease Control and Prevention. This population is more commonly affected, since lymph nodes may be removed during treatment, thus slowing the entire system. The lymphedema network has had a patient questionnaire on its Web site since 2001. Respondents are about equally divided as to whether they have primary lymphedema, which is congenital; or secondary, which seems to be due to a trauma, such as surgery. But even that distinction has blurred as researchers are beginning to understand that everyone's lymph system is not created equal, Dr. Fife said. One person may have a fantastic drainage system that can continue to function well despite a huge assault, such as a radical mastectomy. Another person's system may be less robust and be disrupted by a minor injury. Regardless, any slowdown can lead to the pooling of lymph and its cargo of protein molecules, salts, glucose, urea and other substances. The system carries several liters of fluid a day. An obstruction could result in tremendous amounts of fluid building in the body. Another consequence of obesity The rise in obesity is also contributing to the numbers of lymphedema patients. Ten years ago Dr. Fife didn't have any patients who weighed 500 pounds. Now, 2% or more of her patients are at this weight or heavier. Why morbid obesity leads to lymphedema is unknown, but one theory is that fat may block the system. "So as everyone gets fatter, we have more lymphedema," Dr. Fife said. Morbid obesity is a contributing factor to development of lymphedema. Once a swelling has occurred, avoiding any stress on that body part is essential for preventing recurrences. Patients who have had lymphedema should not have a blood pressure cuff wrapped around the affected limb, or have injections or blood draws, Thiadens said. Go to the opposite arm or the leg. Although there is no cure, controlling the swelling is important. Swelling can become permanent and cause irreversible limb distortions. In addition, other skin conditions can develop, including cellulitis. Plus, the body's defenses are impaired. One of Dr. Fife's patients, for instance, reads meters for the gas company. While tramping through backyards all day, he is bitten by mosquitoes and fire ants, and those bites often lead to infections and hospitalizations. Treatment for lymphedema is a gentle massaging technique, called manual lymphatic drainage, which encourages lymph flow. Once a limb is reduced to near-normal size, efforts switch to compression bandages and garments to keep the swelling down. Although lymph flow maps, complete with roadblocks, have not been available for years -- an earlier mapping technique had been painful and dangerous and was abandoned -- promising research is under way at Baylor College of Medicine, Houston. Fluorescent dye is injected just under the skin, picked up by the lymphatics and transported throughout the system, said Eva M. Sevick-Muraca, PhD, professor of radiology at Baylor and principal investigator for the study. Its path is illuminated by shining near-infrared light on the skin. The light can penetrate several centimeters of tissue. The technique, developed with funds from the American Cancer Society and the National Institutes of Health, has been tested in a phase I trial with normal subjects because, "We don't even know what normal lymph flow looks like," Dr. Sevick-Muraca said. Researchers are beginning to test the system on lymphedema patients, specifically attempting to determine if lymph flow is enhanced by massage. "We image before, during and after the massage and see if the lymph is being pushed into the correct nodal basin," she said. -------------------------------------------------------------------------------- Certain factors can lead to the development of lymphedema and may provide alerts to the cause of swelling in the arms, legs or other body parts. No diagnostic tests are available, but risk factors include: Breast cancer, if the patient received radiation therapy or had lymph nodes removed. Radiation therapy to the underarm area after surgical removal of the lymph nodes. Having a larger number of lymph nodes removed increases risk. Surgical removal of the lymph nodes in the underarm, groin or pelvic region. Radiation therapy to the underarm, groin, pelvic or neck regions. Scar tissue in the lymphatic ducts or veins and under the collarbones, caused by surgery or radiation therapy. Cancer that has spread to lymph nodes in the neck, chest, underarm, pelvis or abdomen. Tumors growing in the pelvis or abdomen that involve or put pressure on the lymphatic vessels and/or the large lymphatic duct in the chest and block drainage. Having an inadequate diet or being overweight may delay recovery and increase the risk for lymphedema. Source: National Cancer Institute With nationwide coverage of a potential surgical “cure” for diabetes, Pittsburgh pharmacist and naturopathic physician, Darrell Misak, recommends education and lifestyle change before what he called “drastic and irresponsible measures.” “I believe people need to be aware that there are short and long term consequences of mini-gastric bypass surgery, even the risk of death,” stated Dr. Misak, who counsels his patients about a natural lifestyle, which he claims promotes general health and longevity. A cursory view of the media headlines on the newly proposed surgical cure for diabetes reveals stories about a pregnant woman losing her fetus, post surgery complications with abdominal pain from adhesions or scar tissue inside the body, lymphedema or swelling due to altered lymphatic circulation, and even death in 4.6% of patients or about 1 in 20 people according to the journal Nature. These are significant concerns and risks for anybody considering this procedure and Dr. Misak believes “this is only the tip of the ice burg as the associated nutrient mal-absorption has the potential to lead to multiple chronic illnesses based on genetic predisposition and dietary nutrient intake.” On the other side of the story, according to Dr. Misak medical literature review shows multiple studies with positive results from a healthy lifestyle that includes a high fiber, low glycemic or sugar diet along with regular exercise, which suggest to prevent or in some cases reverse diabetes and cardiovascular risk factors. He stated that “your lifestyle is a choice and the consequences of that lifestyle are clear in the research,” and he showed considerable disappointment with his perception of the public taking responsibility for their health. He reported seeing multiple patients reverse their diabetes and cardiovascular risks through this approach and added that “nutritional research has given us multiple supportive options to enhance the process.” Either way you look at this issue, it seems to come down to the choices you make along with being informed of potential consequences. Both choices require personal commitment and apparently accepting the responsibility that goes along with that choice. Study Examines Imaging Procedures for Diagnosing Blood Clots in the Lung (Ivanhoe Newswire) – Pulmonary embolism (blood clot in lung vessels) is a common, serious and sometimes deadly condition that is also difficult to diagnose. It’s responsible for 5-10% of all deaths in the United States each year. For 30 years the V/Q (ventilation-perfusion) lung scan has been the chief, non-invasive method of detecting these clots. But now a new study indicates that another test that wasn’t thought to be sensitive enough may actually be a better diagnostic tool. The other test uses computed tomographic pulmonary angiography (CTPA). David R. Anderson, M.D., of Dalhousie University, Halifax, Nova Scotia, Canada and colleagues did a comparison of V/Q scanning and CTPA methods. 1,417 patients considered likely to have acute pulmonary embolism (deep vein thrombosis) were studied at 4 Canadian and one U.S. tertiary care center between May 2001 and April 2005. They were randomized with 716 undergoing V/Q scanning and 701 having CPTA. Preliminary testing for some of the original group did not indicate the presence of a clot or inflammation and those people were given follow-ups for 3 months. The rest were evaluated using one of the two tests. Of the group that had CTPA, 133 (19.2%) were diagnosed with pulmonary embolism or deep vein thrombosis in the initial evaluation period. 101 (14.2%) in the V/Q scan group had a similar diagnosis. The 5% difference in that initial diagnostic period was considered significant. Further results showed that of those who had been considered free of clots initially, only 2 of 561 (0.4%) CTPA patients developed venous thromboembolism in follow-ups as opposed to 6 of 611 patients (1.0%). “The results of our study are reassuring given previous reports of relatively low sensitivity of CTPA for the diagnosis of pulmonary embolism,” the authors write. They go on to say they did not expect to find that CTPA would result in a significant increase in diagnoses. The authors conclude that further research is needed to confirm the clinical importance of some of the emboli found by CPTA in order to decide which patients need anti-coagulant therapy. This article was reported by Ivanhoe.com SOURCE: JAMA Dec. 19, 2007 ---------------------------------- New Findings About Dangerous Cancer Protein (Ivanhoe Newswire) – Researchers are one step closer to understanding why one of the most commonly activated proteins in cancer is so dangerous. A new report from the University of Pennsylvania and Johns Hopkins University finds the Myc protein can stop the production of at least 13 microsRNAs – small pieces of nucleic acid that help control which genes are turned on and off. The study also finds in several cases, re-introducing repressed miRNAs into Myc-containing cancer cells suppressed tumor growth in mice – this means it is possible that a gene-therapy approach could be effective in treating some cancers. Researchers analyzed more than 300 miRNAs in lymphoma cells of humans and mice. They had previously found Myc could turn on one particular group of growth-promoting miRNAs in lymphoma cells. In the cells with high amounts of Myc protein, researchers found big changes in the quantities of at least 13 miRNAs. When researchers took a closer look at the DNA of the lymphoma cells, they found Myc was directly attaching to the DNA at the miRNA genes. “This study expands our understanding of how Myc acts as such a potent cancer-promoting protein,” lead researcher Joshua Mendell, Johns Hopkins University, was quoted as saying. “We already knew that it can directly regulate thousands of genes. Through its repertoire of miRNAs, Myc likely influences the expression of thousands of additional genes. Activation of Myc therefore profoundly changes the program of genes that are expressed in cancer cells.” Researchers also reintroduced several repressed miRNAs into mouse lymphomas with high levels of Myc. When they measured the effect on the progression of lymphoma they found at least five of the miRNAs could stop cancer from growing. Mendell says RNA-based therapies have had some success in animals and it is possible to find a wide range of miRNAs that can stop cancers in their tracks. This article was reported by Ivanhoe.com, which offers Medical Alerts by e-mail every day of the week. To subscribe, click on: http://www.ivanhoe.com/newsalert/. SOURCE: Nature Genetics published online Dec. 2007 MIT Works Towards Engineered Blood Vessels (Ivanhoe Newswire) – MIT scientists are excited about the big step they’ve taken towards being able to transplant tiny engineered blood vessels into tissues such as the kidneys, liver, heart or any other organ that requires large amounts of vascular tissue. The paper is posted this month in an online issue of Advanced Materials. One of the authors, Robert Langer, an MIT Institute Professor, said, “It provides a new way to create nano-based systems with what we hope will provide a novel way to someday engineer tissues in the human body.” The work focuses on vascular tissue that includes capillaries, the tiniest blood vessels that are an important part of the circulatory system. The secret to controlling the cells’ development into tube-like structures is growing them on a surface with nano-scale patterning. “The cells can sense (the patterns),” said Christopher Bettinger, MIT graduate student and lead author. “They end up elongated in the direction of those grooves.” The cells, known as endothelial progenitor cells (EPCs), not only elongate in the direction of the grooves, but also align themselves along the grooves. That results in a multicellular structure with defined edges also called a band structure. “Using the patterned surface takes the guesswork out of the current process of tissue engineer which involves mixing cell types with different growth factors and hoping that a useful type of tissue is produced,” said Bettinger. The next step is to implant capillary tubes grown in the lab into tissues of living animals and try to integrate them. SOURCE: Advanced Materials Online Edition Dec. 2007 Another ‘Smart’ Cancer Drug Can Have Toxic Effects on the Heart (Ivanhoe Newswire) -- Sunitinib, one of the new cancer ‘smart’ drugs is showing a risk for heart failure, heart attack, and hypertension in patients with a cancer called gastrointestinal stromal tumor (GIST). The so-called ‘smart drugs’ are tyrosine kinase inhibitors that target specific signaling molecules inside cancer cells that aid in its spread. A study on another targeted ‘smart’ therapy, imitinib, was reported last year in Nature Medicine, to be associated with heart failure in patients with chronic myelogenous leukemia. Researchers at Children’s Hospital in Boston, Dana-Farber Cancer Institute (Boston) and Thomas Jefferson University(Philadelphia), in a collaborative study, examined cardiac toxicity and sunitinib. This new ‘retrospective analysis’ was lead by Ming Hui Chen, M.D., MMS, a cardiologist at Children’s. In a phase I/II trial at Dana-Farber, 75 patients with imatinib-resistant GIST, who were on multiple cycles of sunitinib were studied. 6 of them (8%) developed symptoms consistent with moderate to severe congestive heart failure and 2 had heart attacks. In all, 8 patients (11%) had some kind of cardio vascular event while taking FDA approved or lower doses of sunitinib. Patients with preexisting coronary artery disease were more likely to develop problems. 19% of the 36 people who were taking the FDA approved dose showed decreases in the left ventricle’s ability to pump blood. 47% developed hypertension. And though hypertension is a common side effect of cancer drugs, the number of patients affected and degree of increase in systolic blood pressure of those taking sunitinib was notable, said Chen. The sunitinib study highlights potential concerns about multi targeted cancer drugs especially in children. These kinds of side effects are especially important to manage in order for children to survive the cancer in good health well into adulthood. “Early identification of cardiac side effects is an important part of keeping patients on life saving cancer therapy over the long term,” says Chen. For the patients in this study, the cardiac dysfunction and hypertension were usually medically manageable. Above all, they were most often able to resume sunitinib therapy after the addition of cardiac medications and/or dose adjustments. SOURCE: The Lancet Dec. 15, 1007 http://www.dailynewstribune.com/homepage/x121490362 Wednesday December 26, 2007 Divine diet helps man get life back by praying off the pounds by Charlotte Ferrell Smith Daily Mail staff MAN - At 295 pounds, Louie Grimmett is a shadow of his former 600-pound self. Divine diet helps man get life back by praying off the pounds Louie Grimmett holds up a pair of pants he wore when he weighed 600 pounds.Using the power of prayer, he has lost more than 300 pounds and his wife, Barbara, has shed more than 60 pounds. Louie prayed for guidance and strength and then did his part to eat .. The 47-year-old Logan County man did not have surgery, join a gym, or enroll in a weight-loss program. He prayed the pounds away. Click here for video of Louie Grimmett talking about how he prayed the pounds away "I was a big boy," Grimmett said. "I used to ride a four-wheeler. It was all I could do to get out to the driveway to get to the four-wheeler." Unable to walk more than a few steps, the cycle was the only way he could get around on his own. He could not fit behind the wheel of a car and depended on his wife to drive him. He ordered clothes off the Internet because it was impossible to find pants with a 72-inch waist and shirts in size 7X in stores. As the weight ballooned, his health deflated. Around this time last year, Grimmett was hospitalized with congestive heart failure and suffered Lymphedema as his swollen legs wept fluid. He was treated with antibiotics and diuretics and told if he did not lose weight that he would die. Severely depressed and nearly immobile, Grimmett began to pray. "I said 'Lord, I can't do this," Grimmett said. "I wasn't living. I was taking up space. I didn't know what to pray for. I just knew I needed help. I was at my lowest point. Sometimes you have to hit bottom before you look up." Grimmett did janitorial and maintenance work at Logan General Hospital until he became disabled from a back injury in 1998. That is when his eating began to spin out of control and he packed on the pounds. He and wife, Barbara, tried to count the number of calories he once consumed in a day but gave up at 12,000. A typical breakfast once included four fried eggs, an entire can of biscuits, a mound of fried potatoes, gravy, and four pieces of sausage. There was no separating lunch, dinner and snacks because eating was an ongoing process throughout the day. He would consume cookies, cakes, candy bars, chips, entire rolls of bologna, and packages of crackers washed down with milk. He drank a dozen sugar-laden sodas a day. He also loved take-out fried fare. Because he could not fit in a booth, he could only eat in restaurants with sturdy chairs. Without any nutritional knowledge, Grimmett asked God to help him change. "I did my part," he said. He began researching nutrition on his computer, learned to read food labels, and began to exercise. At first, he could only stand for a minute or so to strengthen his back. Then he began walking, adding a few steps as he could. As his walking increased and he felt better, he burned additional calories by washing cars and cutting grass for neighbors. He now drives himself to the store, diligently reads food labels, does his own cooking, and walks two to four miles every day. He eats 1,500 calories a day as he consumes a diet rich in fruits and vegetables instead of fats. Ground turkey is used for everything from sandwiches to lasagna. He highly recommends I Can't Believe It's Not Butter. He never feels hungry and enjoys his meals more than ever. He now wears a 2X shirt and jeans with a 46- to 48-inch waist. He weighs himself once every two weeks at a local recycling center where he knows the scales are accurate. As his wife has changed her eating habits and joined the walks, she has shed 63 pounds. Aside from their sizes, their grocery bill has dwindled from $900 to $500 a month for a family of three. Louie and Barbara are the parents of 18-year-old Amanda, who lives with them. Barbara also has two grown children from a previous marriage. Tammy Crosby, 37, and Michael Crosby, 34, both live in North Carolina. The couple said their entire lives have changed. They had a garden over the summer. He recently went hunting with his buddies. And Louie names as his greatest accomplishment the ability to stand and sing at the Greenville Freewill Baptist Tabernacle. They hope to take a beach vacation this year. And Louie would love to fly and be on a show, such as Oprah. "I've never been on a plane," he said. "I couldn't walk through the terminal or fit in the seats. Now I'd love to get on one." However, he wonders if television is ready to air a faith-based plan. With a consistent weight loss and excellent reports regarding blood pressure and cholesterol, Grimmett said his doctor has told him to keep praying. He has considered a 250-pound goal weight for his 6-foot-2-inch frame but will leave that in the Lord's hands as he does his part to stick to what he calls a lifestyle change and not a diet. He said if he had to give his health plan a name, it would be the Jesus Bypass. "I trust in Jesus and bypass the rest of it," he said. "I trust in the Lord and let him take control. This ol' boy prays every day. There is no way I could repay him. Every day I thank him and ask for help." THANJAVUR: Dr. Sinnamohideen Jamal, retired professor of plastic surgery, Thanjavur Medical College Hospital, has been awarded the “Lifetime Achievement Award” by the International Society of Lymphology. The award was presented to him at the 21st International Congress of Lymphology at Shanghai in China on September 26. He is the first recipient of the award. A pioneer in lymphology in India, Dr. Jamal has vast experience in filarial lymph edema and is one of the top surgeons in the field. Committed to treating filarial patients, he has attended to more than 50,000 patients. He developed Nodo-Venous shunt operation for the treatment of filarial elephantiasis in 1970 and has performed thousands of surgeries till date with 90 per cent success rate. He graduated from the Madurai Medical College in 1960 with a gold medal for surgery. He passed the FRCS Glasgow and Edinburgh in 1964 and passed the plastic surgery board examination at Americal College of Plastic Surgeons in 1967. After returning to India in 1967, he started the plastic surgery unit at Thanjavur Medical College Hospital and elevated it to train M.Ch plastic surgery. He was also responsible for setting up the filarial clinical research ward with 10 beds at the hospital. The World Health Organisation held its 12th scientific working group meeting on filariasis at Thanjavur Medical College Hospital in 1985. He was instrumental in bringing together lymphologists and WHO filariasis scientists together. In 1981, Dr. Jamal conducted a double blind trial on coumarin for filarial patients with Prof. John Casley Smith, University of Adelaide, Australia, and research on filarial fever with Prof. W.L. Olszewski, plastic and reconstructive surgeon, Polish Acade of Sciences, Warsaw, Poland, all of them funded by WHO. The surgeons of Thanjavur congratulated Dr. Jamal for his achievements in lymphology and winning the highest award. It may also help prevent the spread of cancer, according to a team from the University of North Carolina at Chapel Hill School of Medicine. Adrenomedullin, which is secreted by cells throughout the body, is known to play a role in cardiovascular disease and other cell functions. In a new study, the UNC group found that adrenomedullin also plays an important role in the formation of the lymphatic system in mice. They said it may be possible to develop drugs that target this hormone in order to help the more than 100 million people worldwide who suffer from lymphedema. The condition occurs when the lymphatic system fails to work properly. In rare cases, it is genetic, but millions suffer lymphedema due to parasitic infections or as the aftermath of cancer therapies. Currently, the only treatments for lymphedema include massage and the use of low-compression stockings and other garments. But these aren't much help, the UNC researchers said. "Our research also may lead to therapies to prevent cancer cells from traveling through these lymphatic vessels to infiltrate other parts of the body," senior study author Kathleen M. Caron, assistant professor of cell and molecular physiology and genetics, said in a prepared statement. The study is published in the Dec. 20 issue of the Journal of Clinical Investigation. More information The Society for Vascular Surgery has more about lymphedema. Interstitial magnetic resonance lymphography: is it a new method for the diagnosis of lymphedema? Int Angiol. 2007 De Dimakakos E, Koureas A, Koutoulidis V, Skiadas V, Katsenis K, Arkadopoulos N, Gouliamos A, Vlachos L. Vascular Unit, 2nd Department of Surgery, University of Athens edimakakos@yahoo. gr. AIM: The aim of this study was to evaluate the method of interstitial magnetic resonance lymphography (MRL) as an examination for the depiction of the lymphatic system in humans in comparison with the method of direct X-ray lymphography. METHODS: We studied 6 persons, 2 volunteers and 4 patients with clinical suspicion of lymphedema in lower extremities. We administered subcutaneous gadobutrol for the MRL with a volume of 5 mL composed of 4.5 mL of Gadobutrol mixed with 0.5 mL of lidocaine hydrochloride and after 7 days lipiodol in the lymph vessel for the X-ray direct lymphography (in 3 patients) in order to compare the findings of the two METHODS: We then followed up all individuals for 7 days for any possible side effect of the contrast agents. RESULTS: Using MRL, we depicted the lymphatic system (lymph vessels and inguinal lymph nodes) of volunteers in 60 min. Moreover, in patients we depicted several abnormalities of the lymphatic system including decreased number of lymph vessels, lymphocele and ectatic lymph vessels. X-ray direct lymphography confirmed the findings of the MRL in all cases. No side effects were observed. CONCLUSION: In our pilot study, Gadobutrol seems to be a good contrast agent for the painless depiction of the lymphatic system in humans through interstitial MRL. More extensive studies are needed in order to establish the efficacy and the dosage of Gadobutrol. PMID: 18091705 [PubMed - in process] What AM I? AM Is A Regulator Of Vascular System Functionality ScienceDaily (Dec. 21, 2007) — The two vascular systems in mammals develop sequentially during embryonic life. The blood vascular system, which is essential for the delivery of oxygen and nutrients to the tissues, develops first. This is followed by the lymphatic vascular system that returns extracellular fluid and proteins back to the blood vascular system from the spaces between the tissues. -------------------------------------------------------------------------------- New data reported in two studies in the Journal of Clinical Investigation has identified signaling by a peptide known as AM in the development of both the blood and lymphatic vascular systems in mice. How the two groups observe similar mouse phenotypes but one concludes they are due to lymphatic vascular system defects and the other to blood vascular defects is discussed in an accompanying commentary by Mark Kahn from the University of Pennsylvania, Philadelphia. Kathleen Caron and colleagues at the University of North Carolina, Chapel Hill, showed that mice lacking AM or either one of the two components of its receptor (Calcrl and RAMP2) died mid-gestation after developing interstitial lymphedema without hemorrhage. Detailed analysis indicated a defect in these mice in lymphatic vascular development, and in vitro experiments demonstrated that AM signaling through Calcrl/RAMP2 drives the proliferation of lymphatic endothelial cells. The authors therefore suggested, "that lack of lymphatic proliferative signals during lymphangiogenesis results in smaller, lower-capacity jugular lymphatic vessels that are unable to accommodate the normal uptake of extravasated fluid and thus exacerbates massive interstitial edema." Similarly, Takayuki Shindo and colleagues from the Shinshu University Graduate School of Medicine, Japan, established that mice lacking RAMP2 died mid-gestation due to severe edema and hemorrhage. However, they observed that the arterial walls of these mice were abnormally thin and their typical structure was severely disrupted. Furthermore, overexpression of RAMP2 in endothelial cells enhanced their ability to form blood capillaries in vitro. The authors therefore concluded that, "RAMP2 is a key determinant of the effects of AM on the vasculature and is essential for angiogenesis and vascular integrity in mice." Article: Adrenomedullin signaling is necessary for murine lymphatic vascular development. Journal of Clinical Investigation. December 20, 2007. Adapted from materials provided by Journal of Clinical Investigation. Need to cite this story in your essay, paper, or report? Use one of the following formats: APA MLA Journal of Clinical Investigation (2007, December 21). What AM I? AM Is A Regulator Of Vascular System Functionality. ScienceDaily. Retrieved December 22, 2007, from http://www. sciencedaily.com /releases/2007/12/071220173855.htm Related Stories Cancer. 2007 Dec 17 [Epub ahead of print] Links Manipulative therapy of secondary lymphedema in the presence of locoregional tumors.Pinell XA, Kirkpatrick SH, Hawkins K, Mondry TE, Johnstone PA. Radiation Oncology Department, Emory University School of Medicine, Atlanta, Georgia. BACKGROUND.: Complete decongestive therapy (CDT), including manual lymphatic drainage (MLD) is a manipulative intervention of documented benefit to patients with lymphedema (LE). Although the role of CDT for LE is well described, to the authors' knowledge there are no data regarding its efficacy for patients with LE due to tumor masses in the draining anatomic bed. Traditionally, LE therapists are wary of providing therapy to such patients with 'malignant' LE for fear of exacerbating the underlying cancer, and that the obstruction will render therapy less effective. In the current study, the authors' experience providing CDT for such patients is discussed. METHODS.: Cancer survivors with LE were referred to therapists at 2 Atlanta-area clinics. CDT consists of treatment (Phase 1) and maintenance phases (Phase 2). During Phase 1, the patient undergoes manipulative therapy and bandaging daily until the LE reduction plateaus; at that point, Phase 2 (self-care) begins. At the beginning and end of Phase 1, LE is quantified and differences in girth volume calculated. The results for patients completing Phase 1 therapy for LE in the presence of locoregional masses were compared with results for patients with LE in the absence of such disease. Both volume reduction of the affected limb and number of treatments to plateau were analyzed. RESULTS.: Between January 2004, and March 2007, LE of 82 limbs in 72 patients was treated with CDT and Phase 1 was completed. The median number of treatments to plateau was 12 (range, 4-23 treatments); the median limb volume reduction was 22% (range, -23 to 164%). Nineteen limbs (16 patients) with associated chest wall/axillary or pelvic/inguinal tumors had nonsignificant difference in LE reduction (P = .75) in the presence of significantly more sessions to attain plateau (P = . 0016) compared with 63 limbs in 56 patients without such masses. CONCLUSIONS.: Patients with LE may obtain relief with CDT regardless of whether they have locoregional disease contributing to their symptoms. However, it will likely take longer to achieve that effect. Manipulative therapy of LE should not be withheld because of persistent or recurrent disease in the draining anatomic bed. Cancer 2008. (c) 2007 American Cancer Society. PMID: 18085587 [PubMed - as supplied by publisher] Int Angiol. 2007 Dec;26(4):367-71. ----------------------------------------- Interstitial magnetic resonance lymphography: is it a new method for the diagnosis of lymphedema? Dimakakos E, Koureas A, Koutoulidis V, Skiadas V, Katsenis K, Arkadopoulos N, Gouliamos A, Vlachos L. Vascular Unit, 2nd Department of Surgery, University of Athens . AIM: The aim of this study was to evaluate the method of interstitial magnetic resonance lymphography (MRL) as an examination for the depiction of the lymphatic system in humans in comparison with the method of direct X-ray lymphography. METHODS: We studied 6 persons, 2 volunteers and 4 patients with clinical suspicion of lymphedema in lower extremities. We administered subcutaneous gadobutrol for the MRL with a volume of 5 mL composed of 4.5 mL of Gadobutrol mixed with 0.5 mL of lidocaine hydrochloride and after 7 days lipiodol in the lymph vessel for the X-ray direct lymphography (in 3 patients) in order to compare the findings of the two METHODS: We then followed up all individuals for 7 days for any possible side effect of the contrast agents. RESULTS: Using MRL, we depicted the lymphatic system (lymph vessels and inguinal lymph nodes) of volunteers in 60 min. Moreover, in patients we depicted several abnormalities of the lymphatic system including decreased number of lymph vessels, lymphocele and ectatic lymph vessels. X-ray direct lymphography confirmed the findings of the MRL in all cases. No side effects were observed. CONCLUSION: In our pilot study, Gadobutrol seems to be a good contrast agent for the painless depiction of the lymphatic system in humans through interstitial MRL. More extensive studies are needed in order to establish the efficacy and the dosage of Gadobutrol. PMID: 18091705 [PubMed - in process] ----------------------------------- Ultrasound Q. 2007 Dec;23(4):255-68. Links Imaging and estimation of tissue elasticity by ultrasound.Garra BS. John P. and Kathryn H. Tampas Green & Gold Professor of Radiology, Department of Radiology, University of Vermont College of Medicine, Fletcher Allen Health Care, Burlington, VT. Ultrasound (US) elasticity imaging is an extension of the ancient art of palpation and of earlier US methods for viewing tissue stiffness such as echopalpation. Elasticity images consist of either an image of strain in response to force or an image of estimated elastic modulus. There are 3 main types of US elasticity imaging: elastography that tracks tissue movement during compression to obtain an estimate of strain, sonoelastography that uses color Doppler to generate an image of tissue movement in response to external vibrations, and tracking of shear wave propagation through tissue to obtain the elastic modulus. Other modalities may be used for elasticity imaging, the most powerful being magnetic resonance elastography. With 4 commercial US scanners already offering elastography and more to follow, US- based methods may be the most widely used for the near future.Elasticity imaging is possible for nearly every tissue. Breast mass elastography has potential for enhancing the specificity of US and mammography for cancer detection. Lesions in the thyroid, prostate gland, pancreas, and lymph nodes have been successfully imaged using elastography. Evaluation of diffuse disease including cirrhosis and transplant rejection is also possible using both imaging and nonimaging methods. Vascular imaging including myocardium, blood vessel wall, plaque, and venous thrombi has also shown great potential. Elasticity imaging may also be important in assessing the progress of ablation therapy. Recent work in assessing porous materials using elastography suggests that the technique may be useful in monitoring the severity of lymphedema. PMID: 18090836 [PubMed - in process] --------- Oregon Massage & Lymphedema Clinic opens in Masonic building By Barbara Adams The Estacada News, Dec 19, 2007 Oregon Massage & Lymphedema Clinic, 366 South Broadway Suite 210, is now open in the second level of the old Masonic building. Massage therapist Tamara Nielson offers a wide variety of massage techniques for overall health. Barbara Adams / Estacada News When Tamara Nielson puts her hands on a patient’s shoulders, she moves with experience–as a massage therapist who has suffered pain and found a natural, soothing way to work through it and heal. Nielson, 46, developed lymphedema after being treated for cancer in 1994. She was raising five children and working as a paralegal when her legs began swelling. “The doctors told me to go home, sit in a chair and put up my feet for the rest of my life. I was 33,” she said. But Nielson led an active life and did not accept the advice. So she went on a quest to find a diagnosis and treatment. She searched medical journals at the library, and through her work learned about lymphedema, which is “a chronic swelling of protein fluids in your tissues,” Nielson said. “Because, when they remove lymph nodes or give you radiation, your lymph nodes can no longer draw fluid out of a limb.” She found a clinic in Ballard, Wash., that treats lymphedema. “A form of massage therapy is how you treat it–that’s how they treat it in Europe as part of your after-cancer care,” she said. Now she is a licensed massage therapist specializing in lymphedema, chronic pain, and working with cancer patients. She recently opened Oregon Massage & Lymphedema Clinic in the Masonic building, 366 South Broadway, Suite 210. But massage isn’t just for people suffering from chronic pain; massage is a natural and pleasant way to take care of your body. As Nielson begins her career as a massage therapist, she’s also constantly learning and educating herself on the many forms of massage and the wide variety of ways it can be used. Helping mothers form deep relationships with their babies is another area Nielson is interested in. It’s called baby massage–Nielson will work with the mother to show her how to massage her baby, and how it helps increase the mother-baby bond. Massage also can break the cycle of pain for people who suffer from chronic pain, Nielson said. For individuals who’s work involves trauma, such as firefighters and police officers, massage can aid in recovery. Nielson is offering a half-price special for first visits, and for those who purchase two massages up front will receive their third massage for free. She’s also networking with a variety of health insurance companies. To make an appointment, or to learn more about Oregon Massage & Lymphedema Clinic, call 503-318- 6799. ------ 12 Million New Cancer Cases Worldwide in 2007 (Ivanhoe Newswire) – By the end of the year it is predicted there will be more than 12 million new cancer cases and 7.6 million cancer deaths worldwide – that’s about 20,000 cancer deaths a day. The estimates come from a new American Cancer Society report based on data from the International Agency for Research on Cancer. The report also estimates 5.4 million of those cancers and 2.9 million deaths will be in economically developed countries, while 6.7 million case and 4.7 million deaths will be in economically developing countries. The research shows the three most commonly diagnosed cancers in men in developed countries are prostate, lung, and colorectal cancer; in women they are breast, colorectal, and lung cancer. But in developing countries the three most commonly diagnosed cancers in men are lung, stomach, and liver cancer; and in women they are cancers of the breast, cervix uteri, and stomach. Cancers of the stomach, liver, and cervix are related to infection in these countries. About 15-percent of all cancers around the world are infection-related with a three times higher percentage in developing countries than in developed ones – 26 percent versus 8 percent. “The burden of cancer is increasing in developing countries as deaths from infectious diseases and childhood mortality decline and more people live to older ages when cancer most frequently occurs,” study co-author Ahmedin Jemal, Ph.D., American Cancer Society, was quoted as saying. “This cancer burden is also increasing as people in the developing countries adopt western lifestyles such as cigarette smoking, higher consumption of saturated fat and calorie-dense foods, and reduced physical activity.” In both developed and developing countries, the report shows the three most common cancer sites are also the three leading causes of deaths from cancer. This article was reported by Ivanhoe.com SOURCE: Global Cancer Facts & Figures, 2007 ------------------------------------------------------------------------- APRIL 2008 LYMPHEDEMA IN THE NEWS http://news.monstersandcritics.com/health/news/article_1397615. php/Caution_advised_while_doing_sports_after_breast_cancer_operation Health News Caution advised while doing sports after breast cancer operation Mar 31, 2008, 3:08 GMT published on the web April 1, 2008 Bonn - Women who have had breast cancer surgery should avoid rapid backward arm movements while doing fitness because it could badly strain the scar tissue, the German cancer assistance centre in Bonn said. Asian sports such as Tai Chi and yoga and activities such as Nordic walking are more suitable for women who have had breast cancer surgery, the centre said. However, Nordic walkers should be careful to let the sticks go back loosely and not to set them down toward the back, otherwise, the strain on their wound could be too much and it could cause lymphedema. Any exercise that causes pain should be immediately ceased. After breast cancer therapy, pursuing the right sport can counteract shortened muscles, the centre said. Physical activity also can strengthen self confidence, which often suffers in women who undergo breast cancer operations. A long road home Posted By Daniel Williams Kim McColl and her husband Dale Neil used to spend six-months each winter in Florida, from November to April. Then in December 2006 McColl discovered lumps under her arm that she had never noticed before. McColl says she always valued the Canadian health care system but now she is more appreciative of what we have here because of the tribulations she experienced in Florida. The day that she discovered the lumps she tried to make an appointment at a primary care practitioner she had visited in the past. She was refused after explaining her situation and was told the office would not accept cash paying patients. Even though she was there the previous year and had paid with the couple’s insurance policy. McColl suspects that the particular clinic she went to that day only accepts insurance from one company. Fortunately McColl was able to locate a second general practitioner who was willing to take cash. The doctor got her in to Manatee Memorial Hospital in Bradenton, Florida where she was administered a diagnostic mammogram and an ultrasound. The tests found nothing, which McColl later learned could have been caused because the cancer had metastasized. “At the time I did not realize the gravity of the situation,” said McColl thinking like many who have a cancer scare, that it will probably end up being nothing. McColl’s insurance policy covered her for emergency procedures only, the tests at approximately $2000 each were paid out of pocket. The doctor in Florida recommended that she have a fine needle biopsy next but with the medical costs adding up and the possibility of more tests McColl and her husband decided to cut short their Florida trip and return to Napanee. Prior to returning Neil called their family doctor in Napanee to set up an appointment, the family doctor told them that 80 per cent of lumps can be drained. McColl saw her doctor within days of returning in February of 2007 and had the fine needle biopsy at Lennox & Addington County General Hospital the next day. For the next month McColl was submitted to a barrage of tests, “CATscan, MRI, bone scan, endoscopy, colonoscopy they were trying to find the source of the cancer,” recalls McColl, everything happened very quickly. “This was an education we did not want,” says McColl, “it was discovered that the cancer was without a primary source.” On March 27 McColl had 12 lymph nodes removed and and a prophylactic mastectomy. Chemotherapy began for McColl in May but she only made it through the first five treatments, skipping the final treatment because she says it would have finished her. “My body rejected it,” says McColl, “I have an honorary degree in throwing up.” The next complication came in the form of lymphedema or swelling of the limbs caused by a blockage in the lymphatic system. The swelling meant that McColl could not raise her arm above her head so they could localize the radiation therapy. During the summer and fall of 2006 McColl underwent physiotherapy and massage therapy to control the lymphedema. Finally in November of 2007 McColl began the first of 25 radiation treatments that lasted through December. McColl began herceptin treatments in February which will last for a year. The treatments are administered every three weeks in Kingston. A volunteer driver from the Canadian Cancer Society picks her up for her treatment, a service McColl is grateful for. “The Cancer Society has been an invaluable resource,” says McColl, “I have had many different drivers some of whom are cancer survivors.” McColl describes her medical journey as a 26-month ordeal, she still has 10 months of herceptin treatments but is very optimistic about the road to recovery. “I am still on the road, but the main thing is that I am on the road,” says McColl, “all this effort will not go to waste.” McColl plans on attending the wedding of her nephew this summer and maybe down the road heading back to Florida for a holiday. Article ID# 970413 Body Talk: A Time To Heal WEARING STRETCHY BLACK PANTS TO YOGA can be anxiety- producing enough. Wearing a wig is even tougher. And Karen Soltes, director of the therapeutic yoga program at Circle Yoga (3838 Northampton St. NW, 202-686-1104), found that women with breast cancer were uneasy about attending classes even if they really wanted to start — or restart — their practice. So, this Friday, Circle Yoga is launching "Yoga for Breast Cancer Recovery," a six-workshop series (10: 30 a.m.-12 p.m.; the series runs through May 16; price depends on how many classes one attends). "We needed to find a way to make it comfortable," she says. Each session is 90 minutes, but a third of the time will be devoted to relaxation — restorative yoga and yoga nidra, a kind of meditation. "There's a lot of anxiety and tension in the body, understandably, when you have this illness," Soltes adds. In terms of the physical practice, Soltes plans to focus on chest opening and stretching exercises to counteract the effects of radiation. And while other yoga classes may include a great deal of weight- bearing exercises with the arms, they'll be shying away from those poses to limit the risk for lymphedema. http://www.readexpress.com/read_freeride/2008/04/body_talk_a_time_to_heal.php Dr. Chester Plotkin, 82, started the UH Lymphedema Center Saturday, April 05, 2008Wally GuentherPlain Dealer Reporter Beachwood - Dr. Chester Plotkin, 82, founder and director of the Lymphedema Center at University Hos pitals, died Tuesday at the Montefiore Hospice in Beachwood. The Lymphe dema Center, which he estab lished in 1993, became the first hospital-based program in the country. It served as a model for other nationwide clinics. The Beachwood resident retired from private practice in 1997 at the University Suburban Health Center on Green Road in South Euclid. He had been a member of Cleveland Physicians Inc. for 41 years. Although he retired from private practice, Plotkin continued working with the Lymphedema Center until 2004. The program emphasized lymphatic drainage massage that was mainly practiced in Europe until the 1980s, his family said. Plotkin often was invited nationwide to speak about his experiences and findings at medical meetings, college medical schools, hospitals that wanted to institute their own lymphedema clinics, and massage therapy groups. In 1996, he was the guest speaker at the Sir Michael Sobel House, Churchill Hospital, in Oxford, England. Plotkin served as an associate clinical professor at the Case Western Reserve University College of Medicine for 40 years. He taught physical diagnosis and clinical medicine. He was a medical consultant to the Social Security Administration's Court of Appeals for several years. Plotkin had been a volunteer at the Free Clinic in Cleveland. He also volunteered at the Court Community Services for 10 years. In that capacity, he helped assign to various jobs people who had been arrested and ordered to perform community services. When he lived in Shaker Heights, he helped organize the Lomond Association in the early 1960s, and served as the first chairman of the neighborhood association. Plotkin was born in the Bronx. He served in the Army during World War II with a military police unit in England and France. After the service, he graduated from New York University, and received his medical degree from the State University of New York Downstate College of Medicine. Plotkin and his wife, JoAnn, had been married 56 years. http://www.cleveland.com/news/plaindealer/index.ssf?/base/news-1/1207384415226400.xml&coll=2 Breast cancer patients find it helps to move Treatment side effects subside through dance by Meghan Tierney | Staff Writer Brian Lewis/The Gazette Sultana Begum (left) of Rockville practices the Lebed Method, taught by Vicki Ralph, an occupational therapist with Adventist Rehabilitation Hospital of Maryland. At Adventist Rehabilitation Hospital of Maryland, women suffering from chronic pain are moving toward healthier bodies and minds with the help of bubbles, boas and bands of yellow stretchy rubber. More News Amid the violence, a lesson Elrich questions Weast meeting with unions Man charged with drowning his children made prior threats Burtonsville Dutch Market to move to Laurel Damascus Rotary Club folds after five decades The Rockville hospital, Montgomery General Hospital in Olney and Baltimore Washington Medical Center in Glen Burnie are the three hospitals in the state to offer classes in the Lebed Method, a light dance-inspired physical therapy regimen. The therapy is used by those whose movements are limited by lymphedema, a chronic and incurable condition common among breast cancer patients that causes swelling in the limbs and elsewhere in the body. The classes have also become something of a social phenomenon in places such as Washington, where they are offered in 65 different hospitals, community centers and churches, according to Focus on Healing Inc., the non-profit that owns the rights to the therapy. ‘‘It brings fun and silliness. It makes people forget about their fears and concerns for an hour a week,” said occupational therapist Vicki Ralph, a certified Lebed instructor who recommends that her lymphedema patients attend Adventist classes to supplement regular treatments, which involve massage and compression of the affected limbs. Attendance at the weekly class has more than doubled since she began teaching it in the fall, and the five original students remain among the 12 currently enrolled. Participants use props to aid them in light stretching and gentle movements, such as raising and lowering a feather boa and blowing soap bubbles to help with breathing. The exercises can be done sitting or standing, and can be beneficial for people with chronic fatigue, multiple sclerosis, arthritis or other conditions that make movement difficult, Ralph said.‘‘It’s activity, but it’s not too strenuous,” said Susie Sabatano, 36, of Silver Spring, who was diagnosed with breast cancer when she was 28 and developed lymphedema a year later. She found out about the class last fall from Ralph, an acquaintance she met through church. ‘‘It’s not like an aerobics class where you’re trying to get your heart rate up,” she said. Exercise is recommended for people with lymphedema, a condition in which the lymphatic fluids that help the body fight infection build up in the limbs or elsewhere, because it moves accumulated fluid out of swollen areas, according to Ralph. However, physical activity can be difficult for those with severe swelling. ‘‘It puts you in a good mood and gives you energy that you didn’t have before,” said LaQuita Hunteman, 66, of Germantown, who was unable to lift her left arm above her ahead until she began the exercises. She has worn a custom-made compression bandage extending from her hand to her elbow 24 hours a day, seven days a week for the last six years to reduce the swelling. Hunteman, a breast cancer survivor, developed lymphedema after she had 26 lymph nodes removed in 2001. Breast cancer often first spreads to the lymph nodes near the armpits, according to the nonprofit breastcancer.org. The Lebed Method was developed in 2000 by Sherry Lebed Davis, a professional dancer who was diagnosed with breast cancer in 1996. The Adventist classes, which also serve as a kind of support group, feature music such as ‘‘(You Make Me Feel Like) A Natural Woman” and ‘‘I Believe I Can Fly” and plenty of water breaks for socializing. ‘‘You start talking about your cancer and then you start talking about where your family lives,” said Hunteman, who exercises at home and plays the piano for an hour a day to keep her fingers moving. Ralph agreed. ‘‘Some people don’t connect with a support group,” she said. ‘‘This is more upbeat.” http://www.gazette.net/stories/040208/olnenew53622_32360.shtml ------- MHMC Breast Care Clinic focuses on Lymphedema Saturday April 12, 2008 http://www.reporter-times.com/?module=displaystory&story_id=98513&format=html Called the "Stepchild of Medicine," lymphedema has long been ignored by the medical community as a condition that cannot be improved. However, residents have medical professionals in the Morgan County medical community who are aware that lymphedema is a condition that will, in many cases, improve with treatment from a skilled professional. Lymphedema is a common debilitating condition in which excess fluid, called lymph, collects in tissues and causes swelling (edema) in them. This often happens after lymph vessels or lymph nodes in the axilla (armpit) or groin are removed by surgery or damaged by radiation, impairing the normal drainage of lymphatic fluid. Lymphedema may also be due to a mass, such as a tumor, pressing on the lymphatic vessels. Jeanette Dow, OT, CLT, of Morgan Hospital & Medical Center (MHMC), has worked in this medical community for more than 12 years. In addition, she has been practicing as an Occupational Therapist (OT) for almost 26 years. Coincidentally, Dow noticed that her training as an OT specializing in Upper Extremity Rehabilitation left her unprepared for treating breast cancer patients with lymphedema. "The standard practice was to use techniques that were effective for edema management, not Lymphedema," said Dow. "If we don't use complete decongestive therapy, which targets removing the excess plasma proteins from the tissue, we will continuously see a recurrence of the lymphedema fluid and at some point the development of scar-like changes in the tissue of the involved extremity that are not reversible." Dow researched for the most advanced training available in the United States and completed her certification course in 1999. She continued to advance her training through many continuing education courses over the next seven to eight years. In 2007, when MHMC's Regional Cancer Center opened its doors to an expanded service line by adding the Breast Care Clinic, she recognized that as the Cancer Center's breast cancer population continued to grow, so would the need for specialty care of patients developing lymphedema. Dr. Robert Goulet Jr., Medical Director of the Breast Care Clinic, said he is well aware of the benefits of having this kind of therapy. "In my experience, lymphedema is one of the most dreaded complications of breast cancer care," he said. "A therapist with special training in a variety of treatment techniques and genuine concern for this patient population can make the difference between a lifetime of pain and limited function versus a survival free of the constant reminder of their underlying disease." One of the interesting facts about lymphedema, a condition of swelling of a limb or other body area, is that it may not surface until months or years following surgery. Some individuals may awaken, surprised to find their arm swollen. "This swelling might have occurred because the patient did an activity that put a larger than usual fluid load on the lymphatics, such as an injury/trauma, sunburn, airplane ride or unaccustomed activity," said Dow. "Patients should receive education regarding triggers like these and take precautions to avoid them." Dow also brings to the table a good source of information regarding lifestyle modifications as well as occupational performance guidelines to assist those individuals wanting to return to work following breast cancer treatment. According to Dow, there are life changes after breast cancer. "We need to recognize that as medicine continues to improve, cancer survivorship improves as well," she said. "The interval of time in which complications may develop or the duration that symptoms may persist has increased substantially. Many women adopt significant lifestyle changes as a result of their cancer experience that may impact things like exercise, travel, and career choices; all of which may impact their risk of lymphedema. Most of these changes represent progress toward recovery and we encourage our patients to embrace these changes knowing that by observing certain precautions or following a treatment plan developed by a trained specialist, complications can be avoided or minimized." "After all of the doctor visits; after the surgery; after chemotherapy; after radiation therapy; the dust will begin to settle," said Dow. "The key to the long-term treatment of patients with breast cancer in the future is recognizing that with evolving advances in therapy most women will move beyond the life and death struggle they are initially faced with to an outlook focused on survivorship. Concerns for overall quality of life and symptom management must be recognized." Dow has surveyed the patient population serviced by the Breast Care Center at MHMC and has found a strong interest in a survivorship program to meet their needs. An organizational meeting was held March 10 to measure interest and future direction of a program. Due to the sign of support from local residents, a second survivorship meeting has been scheduled for 6:30 p.m. Monday in the CBAC Room at MHMC. For further information, call 765-349-6533. ================================================== Buddy Check 12: Lymphedema Posted: April 12, 2008 04:25 PM EDT Buddy Check 12: Lymphedema By: Christy Hendricks CAPE GIRARDEAU, Mo. - Breast cancer affects one in eight women in a lifetime. Not only do patients have to deal with treatment of the cancer, other health problems can develop from the treatment. Patients who have mastectomies often develop lymphedema. It happens many times after lymph nodes are removed during surgery and fluid builds up in the arm. While there's no cure for lyphedema there is treatment. "After I finished with all the surgery and all the chemo and everything that took all of my time and energy, I noticed that my arm continued to hurt," said Connie Eichhorn. She was diagnosed with breast cancer two years ago. Eichhorn says after 23 lymph nodes were removed from her arm during a mastectomy, she could barely buckle her seat belt and couldn't sleep through the night. After hearing about lymphedema through a support group, she sought treatment from physical therapist Paula Stout. "The treatment of choice for lymphedema is manual lymph drainage. It's not massage. It's a treatment by which we stimulate the lymph vessels to reroute the fluid around that area that's been removed," said Stout. "Like the very first treatment I went home and I think I slept all night which I hadn't done in probably six months," Eichhorn said. Connie receives the manual lymph drainage treatment every week. She also wears a compression sleeve several hours a day to reduce swelling. "Lymphedema is aggravating and it takes a lot of time and it's painful, but compared to the other things that I went through in that year, probably, it's really a much easier thing to deal with," Eichhorn said. Stout says anyone who's had lymph nodes removed probably have a little bit of lymphedema. If left untreated, it could cause infections and hardening of the skin. --------------------------------------- What is lymphedema? Primary lymphedema is caused by a malformation of the lymphatic system. Secondary lymphedema is often caused by surgery removal of lymph nodes, injury, scarring, or radiation therapy. Many breast cancer patients develop lymphedema. Symptoms: Swelling, pain, joint immobility, feeling of heaviness, repeated infections, skin thickening Treatment: Manual lymph drainage - manual treatment technique which improves the activity of the lymph vessels and re-routes the lymph flow around the area of blockage. Compresson therapy - special compression garments are applied to the arm or limb to reduce swelling. Skin and nail care - helps prevent bacterial and fungal growth. Use a low pH lotion to maintain moisture and reduce the chance of an infection. Therapeutic exercise - exercises done while wearing the compression garments to promote the flow of lymph and improve range of motion. ---------------------------------------------------------------------------- Illness inspires trainee therapist The Yomiuri Shimbun Sawako Anada wants to become a therapist so that she can help cancer patients suffering from bloated arms and legs--symptoms of lymphedema, an aftereffect of the disease that she also suffered. In April, Anada, 34, started attending a vocational school in Tokyo specializing in lymphedema therapy. Anada,who ran a livestock meat-processing business in Iwaizumicho, Iwate Prefecture, experienced relief after receiving a special massage from a lymphedema therapist. This prompted her to attend classes to learn how to provide mental and physical care for cancer patients. She hopes one day to return to Iwate Prefecture to work as a lymphedema therapist. Anada was told by her doctor in October 2002 that she had cervical cancer and might only live for six months if she did not undergo surgery. At the time she was busy with her work and raising a child, but nonetheless successfully underwent the life-saving surgery. However, when she left the hospital she had a bloated right leg--a typical symptom of lymphedema. Lymphedema is an aftereffect of surgery to remove lymph nodes and causes limbs to swell when lymph fluid accumulates under the skin. While it is said that more than 100,000 people nationwide suffer from the condition, a silver-bullet treatment has yet to be discovered. Anada resumed her meat-processing business, which meant she was kept standing for hours packing sausages and other products into boxes. One day, she noticed her right leg had swollen by more than 10 centimeters. Besides the disfigurement, lymphedema causes mental anguish, and patients tend to become lethargic. Until this spring, there also were financial burdens associated with tackling the condition. Short-stretch compression bandages and other products that dealt with the symptoms were not covered by insurance. Usually, lymphedema therapists provide a combination of four kinds of care--skin care, body massage, properly applying compression bandages and showing patients how to exercise. Mental care also plays a large part in the treatment. Lymphedema therapists are in short supply in Iwate Prefecture, and only a few hospitals specialize in offering proper lymphedema treatment. Anada's physical and emotional pain was exacerbated by menopausal symptoms and worries over her cancer reappearing. In 2005, however, Anada established a group of gynecologic cancer patients in the Miyako district in eastern Iwate Prefecture. The group's name, Rankyu, comes from the combination of the two Japanese words for "womb" and "ovary." As part of the group's activities, Anada's bloated leg was massaged by a therapist. "The therapist's hands felt so warm. She relaxed my mind and body, which was quite amazing," Anada said. Since then, Anada has been receiving massages several times a year, with the result that her right leg has, more or less, stopped swelling. As five years have passed since her surgery, she decided to attend school to learn how to provide physical and mental relief for cancer patients. She will study for three years to become a therapist, and aims to obtain state licenses for acupuncture, moxibustion, acupressure and massage, as well as qualifications in lymphedema treatment and mental care for cancer patients, which she feels is overlooked. Anada, who has received a great deal of support from her family and friends, said, "I want to discover new possibilities for myself." --------------------------------------------------------------------------------------- SOURCE: Presbyterian Hospital of Dallas Apr 11, 2008 12:00 ETHyperbaric Chamber at Presbyterian Hospital of Dallas Reaches Milestone, Stands at Forefront of 'Atmospheric' Medicine DALLAS, TX--(Marketwire - April 11, 2008) - When the Hyperbaric Medicine Unit at Presbyterian Hospital of Dallas opened 15 years ago, it was one of the only units of its kind in the region. Originally used to treat decompression illness in SCUBA divers and carbon monoxide poisoning, the science of hyperbaric medicine slowly expanded as researchers theorized it could treat other ailments. As the role of hyperbaric medicine has expanded over the years, so has the unit at Presbyterian Hospital. The team of specialized-trained doctors and nurses recently completed their 50,000th treatment, making it one of the busiest hyperbaric programs in the Southwest. "We knew the science was strong for treating acute cases of the Bends and carbon monoxide poisoning, but theories on how well it would impact wound-healing and other diseases were still being investigated 15 years ago," medical director Dr. Jeffrey Stone said. "Through the years, studies have proven time and again that hyperbaric medicine can be an important part of a team-approach to treating complex medical cases." The 1,100-cubic-foot compression chamber uses compressed air at simulated depths of up to six atmospheres to treat patients with chronic non-healing wounds, diabetic foot wounds, bone infections, radiation soft-tissue injuries, and failing skin graphs. Most patients breathe 100 % oxygen while being treated at pressure equivalent to two times normal atmospheric pressure, giving them 10 times more oxygen than sea-level air. The gas levels in the patients' blood and organs undergo all the same physiological changes experienced when deep-sea diving. During normal healing, cells proliferate and divide, releasing growth factors. New blood vessels are created, a collagen matrix is formed, and remodeling occurs. Certain medical conditions alter this course and limit healing. Demand for hyperbaric medicine has increased as diabetes has skyrocketed nationally. Non-healing wounds are a common side-effect of diabetes. "Thousands of diabetic patients undergo surgical amputation every year as a result of non-healing wounds," Dr. Stone said. "These amputees face a long, costly rehabilitation, and permanently reduced mobility and independence. Hyperbaric treatments are an important tool in treating diabetic wounds before it's too late." Other conditions can also lead to the development of non-healing wounds, including peripheral vascular disease, arterial or venous ulcers, traumatic injury, complications following surgery, rheumatoid arthritis, congestive heart failure, lymphedema and other conditions which compromise circulation. The hyperbaric program is a division of Presbyterian's Institute for Exercise and Environmental Medicine, which is a joint collaboration with UT Southwestern Medical Center. http://www.marketwire.com/mw/release.do?id=842925 ====================================================================== ============ Cancer Resource Center helps 300+ in first year 04/17/08 The Cancer Resource Center at Gordon Hospital recently celebrated its first birthday with a party complete with birthday cake and refreshments. “The first year has gone extremely well,” said JoAnn Silvers, nurse navigator at the Cancer Resource Center. “We’ve seen 300 people that have come into the center, and that is not including visitors to the nutritionist, the Image Recovery Boutique or for Lymphedema Therapy.” Silvers adds that in the past year, the center has held several events and screenings to promote early detection of cancer that were well received by the public. In addition, she receives many comments about the convenience of the Image Recovery Boutique, a shop that sells wigs, bras and supplies often needed by cancer patients. For Silvers, helping people is one of the most rewarding parts of the job. “Many of our past clients still come back to visit, even if it is just for a few moments,” she said. “We are happy to hear when they are finished with their treatments and have gone back to work.” Most recently the center has begun hosting the monthly meetings of the Cancer Survivor Group and offering a free Fitness Class for Cancer Patients and Survivors. The Cancer Survivor Group holds monthly meetings the first Tuesday of each month from 6:30 to 7:30 p. m. The fitness class is intended for cancer patients and survivors to help them with their healing process. For more information about the activities at the Cancer Resource Center, call 706-879-4746. http://news.mywebpal.com/news_tool_v2.cfm? pnpID=722&NewsID=895231&CategoryID=3388&show=localnews&om=0 ====================================================================== =============== Researchers identify genes responsible for drug resistance in breast cancer SAN DIEGO — Seven genes that may play a role in resistance to tamoxifen have been identified by researchers from Erasmus Medical Center in Rotterdam. These genes, some of which are new, could provide therapeutic targets for individualized breast cancer treatment or prevention of drug resistance, according to one of the researchers who presented the findings at the 2008 Annual Meeting of the American Association of Cancer Research. “We have investigated the principal causes of tamoxifen resistance by performing genome-wide functional genetic screening,” said Lambert Dorssers, PhD, a cell biologist at the department of pathology at Erasmus. “We established that these ‘Breast Cancer Anti-estrogen Resistance’ genes have a role in clinical breast cancer. The results have shown that the majority of genes are indeed associated with clinical tamoxifen resistance and tumor aggressiveness.” Dorssers presented information about the seven BCAR genes that cause the tamoxifen-resistant phenotype: AKT1, AKT2, BCAR1, BCAR3, EGFR, GRB7 and TRERF1. After identifying these genes, Dorssers and colleagues then further studied 561 estrogen receptor- positive primary breast cancers for tumor aggressiveness and tamoxifen resistance. They identified three genes — AKT2, EGFR and TRERF1 — as having an association with metastasis- free survival, the primary endpoint for tumor aggressiveness. In a separate analysis of breast tumor samples from recurrent patients treated with tamoxifen, the researchers found five genes associated with progression-free survival, depending on the level of expression: BCAR3, ERBB2, GRB7, TLE3 and TRERF1. Moving forward, the researchers are examining how these genes function to pinpoint possible targets for treatment of breast cancer. – by Leah Lawrence More than 50% of women who are diagnosed with breast cancer express the estrogen receptor and of those approximately 50% respond to treatment. Why do the other 50% not respond? That is the question. Why do women who express the estrogen receptor not respond to hormonal therapies? Why does essentially every woman who gets hormonal therapy who lives long enough eventually become resistant to hormonal therapy? This is a huge problem. Unfortunately, when patients with breast cancer or almost any other solid tumor recur, the prognosis is very bleak in terms of long-term survival. The importance of study is enormous. – William N. Hait, MD, PhD Immediate Past President, AACR For more information: Dorssers LCJ. #1582. Presented at: 2008 Annual Meeting of the American Association for Cancer Research; April 12-16, 2008; San Diego. http://www.hemonctoday.com/article.aspx?rID=27666 ---------------------------------------------------------------------------------- COX-2 manifestation in atypia may indicate breast cancer risk Print Email Discuss in our forum Cyclooxygenase-2 enzyme expression could be a biomarker in women with atypia that suggests an increased risk of breast cancer, according to data recently published in the Journal of the National Cancer Institute. Researchers from the University of Michigan, the Mayo Clinic in Rochester, Minn. and the University of Helsinki, assessed the expression of COX-2 in tissue samples of 235 women with atypia. After a 15- year average follow-up, researchers reported that 17% of the women developed breast cancer. COX-2 expression was moderate in 30% and strong in 14% of the 235 samples. Compared with controls, the risk for developing breast cancer increased as the COX-2 expression increased (P=.07). Over-expression of COX-2 was significantly associated with older age when biopsied (>45 years, P=. 01), type of atypia (ductal or lobular, P<.001) and the amount of foci of atypia in the biopsy (P=.02). – by Paul Burress J Natl Cancer Inst. 2008;100:421-427. COX-2 is a longstanding focus of clinical and laboratory research in breast cancer. This inducible enzyme is over expressed in a variety of cancers, including in-situ and invasive malignancies of the breast. In addition, it is a very targetable enzyme, using both narrow agents (ie, celecoxib) and broader ones (ie, aspirin). There are multiple hypothesized causes for COX-2 over-expression in breast cancer but its precise role in pathogenesis is not clear. In this study, researchers explored the expression of COX-2 in pre- malignant lesions. They focused on atypical hyperplasia, a relatively common benign finding, and they noted that COX-2 expression, detected by immunohistochemistry staining, was associated with the risk that breast cancer would subsequently develop. If confirmed, this might allow investigators to identify a subset of women for the development of a chemoprevention strategy using COX inhibitors. – Clifford Hudis, M.D. Chief, Breast Cancer Medicine Service Memorial Sloan-Kettering Cancer Center http://www.hemonctoday.com/article.aspx?rID=27351 BMI linked to overall survival in locally advanced breast cancer In women with locally advanced breast cancer, prognosis is worse among those with high BMI, compared with patients who are normal or underweight. Researchers from University of Texas M.D. Anderson Cancer Center in Houston and Dubai Hospital in United Arab Emirates analyzed data from 602 patients with locally advanced breast cancer who were treated in prospective clinical trials. Patients were divided into three groups based on BMI: =24.9, normal/underweight; 25.0 to 29.9, overweight; =30, obese. Eighty-two percent of patients had non-inflammatory locally advanced breast cancer; 18% had inflammatory locally advanced breast cancer. Compared with overweight and normal/underweight groups, those in the obese category had a higher incidence of inflammatory breast cancer (P=.01). Compared with the normal/underweight population, overall survival and recurrence-free survival rates were worse for those in the obese or overweight categories who had locally advanced breast cancer (P=. 001). The incidence of visceral recurrence was also higher among the overweight and obese groups. – by Stacey L. Adams Clin Cancer Res. 2008;14:1718-1725. This article is important because we are hoping to use any and all information available to help us understand the risks that women with breast cancer face. In other words, we want to make sure that we recognize all of the information that might be valuable in helping to understand how to take care of women with breast cancer. In this instance, we have been informed that women who have a bad prognosis with breast cancer at the time of initial diagnosis will actually have a worse prognosis if they have a higher BMI. This information, therefore, helps us begin to categorize women within a conventional high-risk group — to categorize these women into relatively higher and relatively lower-risk groups with respect to their prognosis. This study does not offer us a means to treat those women differently, but what it can do is suggest to us that if we recognize that there is a particular group of women at higher risk — women with those types of cancer who also have higher BMI — then in the future, we might be able to study that group of women specifically and look for better ways to treat them as a ‘high, high’ risk subset. We do this often in cancer medicine; we try to distinguish, even within a bad disease, those people whose disease is worse because those people in particular would benefit from having better therapies devised for them. This study, in and of itself, is interesting intellectually, but it will not lead anywhere unless researchers now take these women who have been defined as ‘high, high’ risk based on high BMI and try to do something for them. That is why any study like this is done, really, it is not just the intellectual exercise but to help us understand who needs more help and then to begin to figure out ways to get them that help. In medicine, we talk all the time to our patients about the value of maintaining a healthy weight. We know, for example, that the risk for diabetes is reduced if you maintain a healthy weight; we know that risk for cardiovascular disease, stroke, heart attack and high blood pressure will be reduced if you maintain a healthy weight. We believe that there are cancer risks that can be reduced by maintaining a healthy weight, and here is an example of that. There is a reasonably good foundation in this report to be able to say to women, ‘it is valuable to maintain a healthy weight because if you ever are so unfortunate as to develop breast cancer, by having a healthy weight at that time, you are going to make your prognosis better.’ So, I think this adds to the body of evidence that we need to make women aware that maintaining a healthy weight as a lifetime wellness strategy is a good thing to shoot for. I think the messages women get from medical professionals about maintaining a healthy weight are pretty widely disseminated in our culture and our medical care, but every opportunity we have to re-emphasize that and expand women’s understanding of that is worthwhile. So here is another instance in which it has been made clear that maintaining healthy body weight will be advantageous. This adds to the chorus calling for maintaining healthy body weight and it has a particular focus because it is a very important women’s health issue that a lot of women worry about. – Donald W. Northfelt, MD Associate Professor of Medicine, Mayo Clinic, Scottsdale, Ariz. http://www.hemonctoday.com/article.aspx?rID=27265 MAKO Surgical Corp. http://www.makosurgicalcorp.com Eight Glasses of Water: Evidence all wet (Ivanhoe Newswire) -- It’s recommended most people drink eight glasses of eight ounces of water a day. But a new study finds there isn’t much research to support this recommendation. Drinking enough water is touted to be helpful for everything from clearing toxins and keeping organs healthy to warding off weight gain and improving skin tone. But does the research back these claims? Researchers from the University of Pennsylvania found there is a definite lack of research to support or deny these claims. Study authors reviewed published clinical studies that focused on drinking water. They found there is solid evidence that people in hot, dry climates as well as athletes and those with certain diseases have an increased need for water. However, they report the average, healthy individual does not benefit from drinking eight glasses of water a day. Researchers say it’s not even clear where this recommendation came from. Researchers say the studies revealed increased water consumption does not improve kidney function or other organ function. They found there is no research to back the theory that drinking water will make people feel full and curb their appetite. They say there are no studies showing a clinical benefit to one’s skin from drinking water. There is also no solid evidence that drinking water can reduce headaches due to water deprivation. Researchers say what they found instead was a lack of evidence for or against drinking eight glasses of water a day. SOURCE: Journal of the American Society of Nephrology, published online April 2, 2008 ANOTHER INTERESTING ITEM: FDA Deadlines may Hurt Patient Safety (Ivanhoe Newswire) -- Congressionally mandated deadlines may be causing the U.S. Food and Drug Administration (FDA) to rush drugs to market before they are really ready. That’s the key finding from Harvard researchers who reviewed the data on FDA drug approvals. Results showed drugs that were approved right before the deadline were two to three times more likely to be pulled from the shelves over time than drugs approved at a more leisurely pace, and two to seven times more likely to end up needing special “black box warnings” alerting patients to safety issues. These drugs were also two to seven times more likely to be discontinued by manufacturers on a voluntary basis because the demand for them had declined. They were twice as likely to experience a change in manufacturer. The authors explain deadlines were first established for the FDA approval process in 1992, when Congress passed a law saying the agency had to either approve 90 percent of new drug candidates within 12 months or face a drop in funding. The rule was strengthened to 10 months in 2002 and renewed in 2007. Researchers say the bottom line is the FDA is under pressure to approve drugs prior to the deadline, and that could spell trouble for patients. “We found that, while these deadlines speed up the approval process, many drugs are approved right up against the deadline, which might lead to unintended consequences with regard to drug safety,” study author Daniel Carpenter, Ph.D., was quoted as saying. “This suggests that drug safety might improve under an FDA approval protocol that is more flexible and less driven by deadline pressures and more by stable growth in FDA resources.” SOURCE: The New England Journal of Medicine, 2008;358:1354-1361 http://www.ivanhoe.com/channels/p_channelstory.cfm?storyid=18500 NOT LYMPHEDEMA BUT INTERESTING SINCE WE'RE SUPPOSED TO DRINK ALOT OF WATER........ Local minister dealing with wife's illness Submitted Photo Carrie and David Sparks have been married for 42 years, a union that has remained strong even though she has been receiving treatment at a facility in Ohio for more than a year due to a severe stroke. Published: Sunday, April 27, 2008 9:47 PM CDT Tom Joyce Staff Reporter David Sparks now knows the way from Mount Airy to Toledo, Ohio, almost by heart. That's not because Sparks is a long-distance trucker or a traveling salesman whose route encompasses the Buckeye State. Instead, he pastors Flat Rock Pentecostal Holiness Church, and the 500-mile trips he regularly makes to the Toledo area result from his wife, Carrie, being housed there for more than a year after a major stroke. “Just two years ago, I would have never dreamed I would be traveling 500 miles up the road to be with my Miss America,” Sparks said. “That's what I call her.” At first, Sparks, who has been with Flat Rock Pentecostal Holiness Church for 14 years, made the journey each week to be by his wife's side, while also juggling his duties as pastor. But due to “pure exhaustion” and the expense involved, he has had to stretch that out to every other week, or more frequently as the need arises. When asked how many miles he has driven over that time, Sparks replied, “probably 52,000, is what I estimated.” The local pastor admits that the strain of being so far away from his wife of 42 years, not to mention her serious medical condition itself, occasionally has been hard to handle. “At times, I have felt like, why me, Lord?” he said. “But as time goes on, those thoughts pass on by more than they did. Instead of ‘why me?' I think, ‘why not me?'” When he gets down in the dumps over the situation, Sparks said he reminds himself that “it's not about me - it's much bigger than me. “If the shoe were on the other foot,” he added, “my wife would be just wonderful.” Problems snowballed in 2006 Sparks remembers the date of Oct. 18, 2006, well. On that day, Carrie Sparks - a mother of two who sustained a series of mini-strokes in the late 1990s while in her 50s - suffered a serious stroke. She initially was a patient at Forsyth Memorial Hospital in Winston-Salem, before spending time at a rehabilitation facility in Greensboro and later Blue Ridge Nursing Center in Stuart, Va. Then, in January 2007, the local woman suffered another setback when her kidneys failed completely, which has required dialysis treatments three days a week for four hours at a time. “She'll be on dialysis the rest of her life,” her husband said. Also during that winter, a federal judge in Greensboro declared Carrie Sparks legally blind. “At that point, it became necessary to find a long-term care facility that could deal with Carrie's health problems,” her husband recalled. In addition to the vision and other difficulties, including being unable to walk, she was afflicted by diabetes and lymphedema, a condition involving a breakdown of the lymph system in which fluid builds up throughout the system. Such a facility also had to be within close proximity of a dialysis center. An Internet search revealed two locations in the United States where Carrie Sparks' various physical needs could be met - one in Roanoke, Va., and the other in Gibsonburg, Ohio, about 22 miles from Toledo. Naturally, the facility in Roanoke was the first choice, “but they had a long waiting list,” Sparks said. So the decision was made to have his wife treated at Windsor Lane Healthcare Center in Ohio, while also adding her name to the list in Roanoke. “They have really done her good - it's a world-class facility,” Sparks said of the Gibsonburg center that serves patients from across America. “We feel blessed for her to be there.” Carrie Sparks was admitted to the Ohio center on Easter Sunday, March 23, 2007. Then began the regular trips back and forth to Ohio by her husband, who said that he sometimes does not have a choice about his travel plans. Since Sparks has power of attorney for his wife, he must be present for doctor consultations and similar situations. “That stroke left her unable to communicate well, so I have to communicate for her,” the veteran pastor said. The stroke also impaired her memory, so Carrie Sparks, who recently has experienced heart difficulties as well, would have difficulty remembering what the doctors say. She can talk, but her oral skills have been affected by the severe stroke to the point that she is not able to describe objects, or sometimes identifies them by the wrong names. Yet, Carrie Sparks has managed to make it clear that she is comfortable and satisfied with her care. “She has really settled in well to the facility,” the pastor said. The Sparks family also includes the couple's son, Chris; their daughter, Sherry Tipton, and her husband, Darrell; and the Tiptons' young children, Timothy and Tiffany. The grandchildren have been on some of the trips to Ohio. “That's the best medicine she gets all week, is when they show up in her room,” Sparks said. “She is happy - that has meant so much to me and the family,” he added. “The Lord has given her contentment and maybe patience. I don't know what else. But whatever it takes, the Lord has given it to her.” Ordeal brings blessings Sometimes, good does come from bad things, and David Sparks says that in his case, he has been strengthened and encouraged by the support from his congregation at Flat Rock Pentecostal Holiness. “This church has really pulled together,” he said. “They have distinguished themselves, and I am so immensely proud of my wonderful congregation.” A retired minister friend, the Rev. Deward Scott, has delivered sermons in Sparks' place when he has had to be in Ohio. “He's very dependable, and a great, great friend,” Sparks said. “I just can't say enough about Deward Scott.” Meanwhile, two couples at the church, Haywood and Alyene Young and Buster and Sharon Davis, were recruited for those occasions when the pastor ministers to congregation members who are hospitalized for surgery or other crises. “They eagerly accepted my request,” Sparks said. “They go in with the patient and family until the surgery is over, just like I would do if I was here.” The pastor also said that people in the church will call him on his cell phone to keep him company during the long journeys to Ohio, which involve driving on Interstate 77 almost to Cleveland, then heading west on the Ohio Turnpike. “They'll call me all the way up the road.” Buster Davis once talked to Sparks for such a lengthy time during one trip that Sparks said it was if he had picked up a hitchhiker along the way. Davis later told Sparks' children about their father's experience with his “hitchhiker,” which “flabbergasted” them until they heard the full story. “So it was kind of neat,” the Flat Rock pastor said. In praising the support from his congregation, Sparks said he “is grateful for the way the church has rallied together in this highly unusual chapter in the life of this family, and the life of the Flat Rock Pentecostal Holiness Church.” Among other blessings emerging during the ordeal have been friends he has met in Ohio. “There are great people everywhere,” Sparks said. The local resident said he can identify with the situation of a well-known Bible figure, Job, who was faced with all kinds of hardships. But the key was how Job dealt with them. “Job responded in such a marvelous way,” said Sparks, who hopes to also “respond in a way that will glorify the Lord.” This includes possibly serving as an example to others undergoing a similar crisis, so they can forge ahead with life. Sparks agrees that in the course of his wife's illness he has found strength within himself that he never knew was there. “It just constantly amazes me.” http://www.mtairynews.com/articles/2008/04/28/news/local_news/local04.txt Contact: Wendy Lau 212-845-4272 Russo Partners, LLC Preoperative assessment of cancer patients enables early diagnosis, treatment of lymphedema NIH, National Naval Medical Center, George Mason University study published in journal Cancer demonstrates importance of physicians' shift to baseline measures and ongoing 'surveillance' model for successful management of common, debilitating condition BETHESDA, Md., April 30, 2008 – The preoperative assessment of breast cancer patients for subclinical lymphedema enables clinicians to establish a baseline, which serves to enable the early diagnosis and successful treatment of the debilitating condition, according to data from a five-year study published this week in the online edition of the journal Cancer (http://www3.interscience.wiley.com/cgi- bin/abstract/118821880/ABSTRACT). In a study conducted by the National Institutes of Health (NIH) and the National Naval Medical Center, in collaboration with faculty and students from the University of Michigan-Flint and George Mason University, researchers measured the upper limb volume of 196 newly diagnosed breast cancer patients from 2001 to 2006 to establish a baseline prior to surgery. At designated postoperative intervals, the researchers took repeated measurements as part of a “surveillance” model to monitor for possible impairments related to breast cancer treatment--such as lymphedema--as opposed to treating therapy- related problems after they occur. Using the surveillance approach, the investigators demonstrated that a short trial of compression garments effectively treated subclinical lymphedema when it was detected early. Forty-three, or 22 percent, of the 196 breast cancer patients in the study developed subclinical lymphedema, as defined by a change in limb volume of >75cc; and all subjects showed a significant mean volume reduction to very near their pre-surgical “normal” state. All subjects were able to maintain this level for an average of 4.8 months, and none of the patients demonstrated progression of the condition in the follow-up period. Steven Schonholz, M.D., a breast surgeon and medical director of the Breast Cancer Center at Mercy Medical Center in Springfield, Mass., added: "The problem with lymphedema is that there hasn’t been an easy way to detect the condition before it is apparent to the doctor and patient. Today there are new, non-invasive methods that have enabled me to identify the condition and begin treatment long before the patient is aware of a problem. If patients aren't treated at the earliest possible indication of lymphedema, it is less likely to be effectively treated, and the condition may require life-long costly treatment and, more importantly, have an enormous impact on a woman's self-esteem, function and quality of life." While there is no standard tool used to assess the condition, physicians have relied on tape measures and water displacement to track changes in limb circumference and size as well as on patients to report changes in upper extremity mobility. Several diagnostic tools are able to accurately track minute changes in extracellular fluid to allow for the earliest possible detection. These include bioimpedance spectroscopy devices, which use an electrical signal to assess fluid changes in the body. "Optimal management of lymphedema requires diagnostic tools that are sensitive to subclinical changes in tissue," said Dr. Schonholz, who uses an FDA-cleared low frequency bioimpedance device developed by ImpediMed Inc. in his practice. ### About Lymphedema Lymphedema is a condition that can cause significant swelling of the upper and lower extremities due to the build-up of excess lymph fluid. This can occur when the lymphatic system, which is responsible for draining excess fluid from the body and is a key component of the immune system, is damaged or altered. In breast cancer patients, this can occur after surgery, such as removal or biopsy of the lymph nodes, and/or radiation therapy. It is estimated that 6 percent to 40 percent of patients with breast cancer develop lymphedema, and that it often occurs within the first two years after surgery. For some cancer survivors and others at risk, a low level lymphedema can occur 10 years to 15 years following the initial primary treatment and develop into a condition that has a serious impact on overall health and quality of life. Ann Dermatol Venereol. 2008 Apr;135(4):299-303. Epub 2008 [Intravascular B-cell lymphoma with febrile inflammatory lymphoedema of the lower limbs and lower back.] [Article in French] Pallure V, Dandurand M, Stoebner PE, Habib F, Colonna G, Meunier L. Service de dermatologie, groupe hospitalo-universitaire Carémeau, rue du Professeur-Robert-Debré, 30900 Nîmes, France. BACKGROUND: Intravascular lymphomas are diffuse large-cell lymphomas belonging to a group of high-grade non-Hodgkin's lymphomas and are generally of phenotype B. They are rare and carry a severe prognosis. Clinical polymorphism is dominated by neurological and cutaneous involvement. PATIENTS AND METHODS: We report the case of an 80-year-old woman with cutaneous intravascular B-cell lymphoma as revealed by an isolated episode of febrile bilateral inflammatory lymphoedema. Following combined chemotherapy with rituximab and mini-CHOP (cyclophosphamide, adriamycin, oncovin and prednisone), complete remission was obtained rapidly, with no relapse at two years. DISCUSSION: Diagnosis of these tumours is rendered difficult by the clinical polymorphism and multifocal nature of lymphocytic proliferations. In the present case, diagnosis was based on histology results since presentation of the disease in the form of bilateral inflammatory oedema of the lower limbs is not sufficient to establish lymphoma. Combined rituximab and polychemotherapy comprising a CHOP regimen appears to yield the best results. PMID: 18420078 [PubMed - as supplied by publisher] ELLENSBURG – Marian Reichelt of Snohomish is no stranger to fishing, she just never has done it quite like she did Saturday on the Upper Yakima River. She’s fished lakes and streams for salmon and steelhead alongside her husband in the Lake Chelan area, but she’s never fly fished with 11 other women, all breast cancer survivors, many of whom would never think to step into a rocking drift boat on a chilly, unseasonable spring day. Yet the women did just that. Twelve of them, all patients of Northwest Hospital in north Seattle, along with selected hospital staff and local fishing guides, sought the wily trout in nine boats most of the day Saturday. The Puget Sound-area women were given the fly-fishing experience free as part of a twice-a-year outing that’s into its fourth year thanks to Northwest Hospital and, this year, due to generous donations from doctors and specialists. “It’s something I’d always wanted to try,” said Reichelt, 50, as she got ready to leave the Yakima River Fly Shop in downtown Cle Elum Saturday morning with her guide for the trip to the push off point. “It’s been on the top of my list of things to do for quite a while.” Reichelt, for quite a while, has been occupied, to say the least. For the past four years she’s been on journey of survival that’s included a mastectomy, repeated rounds of what she called “aggressive chemotherapy” and radiation treatment. “I’m doing some added treatment, but I can say I’m cancer free right now,” Reichelt said. “When I look at it all, I believe it’s made me a stronger person.” Therapy Using fly-fishing as physical therapy for strengthening is part of the goal of the outings that were started by Dr. Sandra Vermeulen, a radiation oncologist at Northwest Hospital. The physical work of casting a fly with rod in hand exercises the arm and shoulder in such a way that it steers the women away from a common side effect of breast cancer treatment. The side effect is lymphedema, a painful swelling in the arms and upper body that can lead to permanent loss of mobility. About one in five women who’ve had breast cancer will get lymphedema, but exercise is one way to prevent it or lessen its impact. Vermeulen said she’s been an avid fly-fisher for many years, and the Upper Yakima is one of her favorite spots. “All of these women have had surgery and some very hard treatment,” Vermeulen said Saturday before heading on to the river. “These are some pretty tough ladies; they’ve been through a lot.” She said in addition to the therapy, the beautiful, riverside scenery, the friendship of other women and the excitement of fishing helps the women “refocus their lives. They see that life can still be great out there.” Local help With the support of Northwest Hospital, Vermeulen started the biannual trips with the help of local fishing guide Charles Cooper of Cle Elum and Yakima River Fly Shop owner/guide Jim Gallagher. The two men help organize the trip’s logistics, and each travels to Seattle the week before the trips and gives a five-hour fly-fishing lesson to a portion of the women. The men each bring a drift boat along to their lesson and drag it on to the grass at the Seattle hospital’s campus. The women get a feel for what being in a small boat is all about while fly-casting at the same time. Cooper said women ranging from 30 years old to nearly 70 have been on the trips. Nine fishing guides accompanied the women. “These ladies have just survived probably the most traumatic experience of their life,” Cooper said Saturday. “For me, I want to give them a great adventure, and I want them to enjoy the camaraderie of other survivors.” He said assisting the women is personal for him: his mother is a breast cancer survivor. For Jim Gallagher, it’s personal, too. Before heading to the river Saturday morning, he said his mother died from breast cancer. “I grew up in a fly-fishing family; all of us fished together,” Gallagher said as his voice softened. “My entire life has been involved with fly-fishing.” Sisterhood Reichelt said she jumped at the chance to fly-fish with a guide when her doctor offered her the invitation. “It’s really a neat experience on the river, especially with these other women who have an experience in common,” Reichelt said. “You could say we’re a band of survivors, a sisterhood. If you haven’t gone through cancer treatment you can’t really understand what one really goes through. It’s so hard to explain. “We’ve all faced the same situation. I guess we’re all in the same boat, so to speak. We’ve been through the whole thing and made it back.” A stitch in time brings relief PATRICE ST. GERMAIN patrices@thespectrum.com ST. GEORGE - Sewing machines whirred as members of the American Sewing Guild put together "anti- ouch pouches" at the local Bernina store on Friday. The pouches are pillows that hang from the shoulder and fit snuggly under the arm to provide a cushion and keep the arm away from the body after breast surgery or during radiation treatment. The pillows will be inclu-ded in post-mastectomy care kits given to patients at Dixie Regional Medical Center. "The pillows are something very simple but it has great importance for our post-mastectomy patients," Lorraine Moe said. Moe is an occupational therapist and certified lymphedema therapist working in the Dixie Regional Medical Center rehab services center. She said a lot of times after mastectomy surgery, patients have edema - fluids caused by the surgery - and have drains in place, which cause pain and tenderness in the area around and under the arm. The pillow prevents friction against the tender area and Moe said not only does it help reduce the pain, but it comforts the patient. "Because a drain can be there several days, up to a couple of weeks, the pillow is more of a sense of comfort knowing that the area is not rubbing," Moe said. Moe said for post-mastectomy patients, even something as simple as vibration from sitting in a car may cause pain in the surgical area. Ruthann Adams said the local sewing group is made up of members of the St. George Neighborhood Branch of the Las Vegas Sewing Guild, which is part of the American Sewing Guild. Frequently, the group gets together to make items such as the anti-ouch pillows as projects to help members in the community. As a breast cancer survivor, Adams knows how important the pillow can be. The pillow was designed by Deon Maas, a breast cancer survivor and member of the American Sewing Guild. Komen awards local grants From submitted reports Three Baxter Regional Medical Center programs have received grants from the Susan G. Komen for the Cure Arkansas Affiliate totaling nearly $113,000. The Mobile Mammography Unit (MMU) received $105,080, the Lymphedema Outreach Program received $4,050 and the Tell Your Mom, Save a Life Program received $3,679. Mobile Mammography Unit The Komen grant is the primary source of funding for the MMU that makes mammograms convenient and affordable. Housing the mammography equipment in an RV-type vehicle makes it possible to take this lifesaving screening to various locations throughout Baxter, Marion and surrounding counties. The MMU also offers bone density testing. Most of the approximately 11,000 patients served by the MMU since BRMC first began this outreach in 2001 have said they probably would not undergo regular checks were it not for the MMU. Many said they would probably never get a mammogram without the MMU. Last year, the MMU did 2,769 screenings. To schedule the unit, call (870) 508-2666. Lymphedema Outreach The Lymphedema Outreach Program, started four years ago by physical therapist Reneé Barnes, is entirely funded by the Komen grant. Lymphedema is a condition that causes swelling in the trunk and extremities. It is common following breast cancer and related treatments. Grant money is used to purchase compression garments to help control the symptoms and complications of lymphedema. Barnes also produced a video — "Management of the Lymphedematous Extremity" — for distribution to survivors as a tool to reinforce their management techniques at home. The grant money also has provided education and certification in lymphedema therapy for an additional therapist. The BRMC Rehabilitation Services Department now has three staff members — Barnes; Jason Smith and Arlette Michalak — who are certified in the treatment of lymphedema. A new facet of treatment was recently added to the outreach program as therapists were trained in the use of the "Lebed Method" of lymphedema therapy. This method incorporates dance movement and therapeutic exercise to help lymphedema sufferers. Tell Your Mom, Save a Life The Tell Your Mom, Save a Life initiative takes breast-cancer awareness and education to junior and senior girls in area schools. They are encouraged to share this information with their mothers and other female relatives. Nearly all the girls reached by the program indicated by survey that they would pass along the information. As part of the program, the girls learn when and how to do a breast self-exam (BSE). The outreach also stresses the importance of mammograms for women age 40 and older. Each girl receives a packet of information about breast cancer, BSE and mammograms. They learn about the BRMC MMU and the Susan G. Komen Race for the Cure. During the 2007-08 school year, BRMC Women's Health Education Center Coordinator Angi Nix presented the program to 15 schools and handed out 730 packets of information. Komen for the Cure This year, Komen for the Cure Arkansas Affiliate handed out checks to 28 Arkansas organizations. Grants awarded totaled more than $1.2 million. "We are thrilled that our grant program continues to grow after 14 years," said Arkansas Affiliate Executive Director Sherrye McBryde. "This year we awarded $1,205,221 to 28 very worthwhile breast cancer projects around the state." The Komen Arkansas Affiliate first awarded grants totaling $78,700 in 1994. "The support that Arkansans provide to Komen for the Cure through the Race for the Cure and other events continues to grow with each year," McBryde said. "It is because of that support that we are able to offer grants to worthy organizations dedicated to the fight against breast cancer." Komen for the Cure was established as the Komen Foundation in 1982 by Nancy Brinker to honor the memory of her sister, Susan G. Komen, who died from breast cancer at the age of 36. Komen for the Cure has raised nearly $600 million for the fight against breast cancer. 1002 Nature Methods - 5, 431 - 437 (2008) Published online: 20 April 2008; | doi:10.1038/nmeth.1205 Modeling lymphangiogenesis in a three-dimensional culture system Françoise Bruyère1, Laurence Melen-Lamalle1, Silvia Blacher1, Guy Roland1, Marc Thiry2, Lieve Moons3, Francis Frankenne1, Peter Carmeliet4, 5, Kari Alitalo6, Claude Libert7, 8, Jonathan P Sleeman9, 10, Jean-Michel Foidart1, 11 & Agnès Noël1 1 Laboratory of Tumor and Developmental Biology, Groupe Interdisciplinaire de Génoprotéomique Appliqué–Cancer, University of Liège, Avenue de l'Hôpital 3, B-4000 Liège, Belgium. 2 Laboratory of Cell and Tissue Biology, University of Liege, rue de Pitteurs 20, B-4020, Liège, Belgium. 3 Laboratory of Neural Circuit Development and Regeneration, Zoological Institute, Katholieke Universiteit Leuven, Naamsestraat 61, B-3000 Leuven, Belgium. 4 Department for Transgene Technology and Gene Therapy, Vlaams Instituut voor Biotechnologie, Onderwijs en Navorsing building I, Herestraat 49, B-3000 Leuven, Belgium. 5 Center for Transgene Technology and Gene Therapy, Katholieke Universiteit Leuven, Naamsestraat 61, B-3000 Leuven, Belgium. 6 Molecular Cancer Biology Program, Ludwig Institute for Cancer Research, Biomedicum Helsinki, Haartman Institute, P.O. Box 63 (Haartmaninkatu 8), FI-00014 University of Helsinki, Finland. 7 Department for Molecular Biomedical Research, Universiteit Gent Vlaams Instituut voor Biotechnologie, Technologiepark 927, B-9052 Gent, Belgium. 8 Department of Molecular Biology, Ghent University, Technologiepark Zwijnaarde 927, B-9052 Ghent, Belgium. 9 Forschungszentrum Karlsruhe, Institut fur Toxikologie und Genetik, Postfach 3640, D-76021 Karlsruhe, Germany. 10 Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, D-68135 Mannheim, Germany. 11 Department of Gynecology, Centre Hospitalier Universitaire, Blvd. du 12ème de Ligne, B-4000 Liège, Belgium. Correspondence should be addressed to Agnès Noël agnes.noel@ulg.ac.be A lack of appropriate in vitro models of three-dimensional lymph vessel growth hampers the study of lymphangiogenesis. We developed a lymphatic ring assay—a potent, reproducible and quantifiable three- dimensional culture system for lymphatic endothelial cells that reproduces spreading of endothelial cells from a pre-existing vessel, cell proliferation, migration and differentiation into capillaries. In the assay, mouse thoracic duct fragments are embedded in a collagen gel, leading to the formation of lumen- containing lymphatic capillaries, which we assessed by electron microscopy and immunostaining. We developed a computerized method to quantify the lymphatic network. By applying this model to gene- deficient mice, we found evidence for involvement of the matrix metalloproteinase, MMP-2, in lymphangiogenesis. The lymphatic ring assay bridges the gap between two-dimensional in vitro models and in vivo models of lymphangiogenesis, can be used to exploit the potential of existing transgenic mouse models, and rapidly identify regulators of lymphangiogenesis. Nature Methods - 5, 439 - 445 (2008) Published online: 6 April 2008; | doi:10.1038/nmeth.1198 Spheroid-based engineering of a human vasculature in mice Abdullah Alajati1, 2, 3, 6, 7, Anna M Laib1, 7, Holger Weber2, 6, 7, Anja M Boos1, 2, Arne Bartol1, Kristian Ikenberg2, Thomas Korff2, 6, Hanswalter Zentgraf4, Cynthia Obodozie2, 6, Ralph Graeser5, Sven Christian1, 2, Günter Finkenzeller3, G Björn Stark3, Mélanie Héroult1, 2 & Hellmut G Augustin1, 2 1 Joint Research Division Vascular Biology of the Medical Faculty Mannheim (CBTM), University of Heidelberg, Ludolph-Krehl-Str. 11-14, D-68167 Mannheim, Germany, and the German Cancer Research Center (DKFZ), Im Neuenheimer Feld 581, D-69120 Heidelberg, Germany. 2 Department of Vascular Biology and Angiogenesis Research, Tumor Biology Center, Breisacher Str. 117, D-79108 Freiburg, Germany. 3 Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Hugstetter Str. 55, D-79106 Freiburg, Germany. 4 Electron Microscopy Group, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, D-69120 Heidelberg, Germany. 5 ProQinase GmbH, Breisacher Str. 117, D-79108 Freiburg, Germany. 6 Present addresses: Friedrich-Miescher Institute, Maulbeerstrasse 66, CH-4058 Basel, Switzerland (A. A.); ProQinase GmbH, Breisacher Str. 117, D-79108 Freiburg, Germany (H.W., C.O.); Department of Physiology, University of Heidelberg, Im Neuenheimer Feld 581, D-69120 Heidelberg, Germany (T.K.). 7 These authors contributed equally to this study. Correspondence should be addressed to Hellmut G Augustin augustin@angiogenese.de The complexity of the angiogenic cascade limits cellular approaches to studying angiogenic endothelial cells (ECs). In turn, in vivo assays do not allow the analysis of the distinct cellular behavior of ECs during angiogenesis. Here we show that ECs can be grafted as spheroids into a matrix to give rise to a complex three-dimensional network of human neovessels in mice. The grafted vasculature matures and is connected to the mouse circulation. The assay is highly versatile and facilitates numerous applications including studies of the effects of different cytokines on angiogenesis. Modifications make it possible to study human lymphangiogenic processes in vivo. EC spheroids can also be coimplanted with other cell types for tissue engineering purposes. April 2008: Preventing and Treating Arm Lymphedema Key Questions from this Conference “Is there any 100%-positive way to prevent lymphedema?” Answer. “I'm wondering what exercises can help prevent lymphedema? Can I lift weights at all on the affected arm, even just 5 lbs?” Answer. “How can I tell the difference between the swelling in my arm and breast from radiation (I am 2 months out of treatment) and the signs of lymphedema?” Answer. “Is it safe to get a manicure if you have arm lymphedema?” Answer. The guest speakers for this conference were Kathryn Schmitz, Ph.D., M.P.H., F.A.C.S.M. and Nicole Stout Gergich, M.P.T. C.L.T.-L.A.N.A. The moderator was Jennifer Sabol, M.D., F.A.S.C. Kathryn Schmitz, Ph.D., M.P.H., F.A.C.S.M. is assistant professor in the division of clinical epidemiology at the University of Pennsylvania and adjunct associate professor in the division of epidemiology at the University of Minnesota. She leads a number of research studies, including a study examining physical activity and lymphedema in breast cancer survivors. Dr. Schmitz has won multiple awards from the American Heart Association, including the Jeremiah Stamler Award for New Investigators and the Trudy Bush Fellowship for Cardiovascular Research in Women's Health. Nicole Stout Gergich, M.P.T., C.L.T.-L.A.N.A. is a physical therapist and lymphedema specialist at the Breast Care Center at the National Naval Medical Center. She is also the president of the oncology section of the American Physical Therapy Association, and has previously served on the Medical Advisory Board and research committee for the National Lymphedema Network. Ms. Stout Gergich has lectured internationally on the topics of lymphedema and cancer rehabilitation. Areas of specialization within the lymphedema population include head and neck, breast reconstruction, stage III management, and wound care. Jennifer Sabol, M.D., F.A.C.S. is a breast surgeon who directs the newly developed Breast Care Center at Lankenau Hospital in Wynnewood, Pa. For the past 9 years, Dr. Sabol has held an appointment at Jefferson Medical College as a clinical assistant professor of surgery. Among her many interests, Dr. Sabol spearheads several research initiatives to advance the care for women with breast cancer and improve methods of breast cancer detection and treatment. She has appeared on CNN to discuss breast cancer-related issues and is a frequent lecturer. Dr. Sabol is also a member of the breastcancer.org Professional Advisory Board. breastcancer.org: Welcome! Thanks for joining our special breastcancer.org Ask-the-Expert Online Conference: Preventing and Treating Arm Lymphedema. As much as possible, we'll answer those questions that cover the topics most of you are interested in. We'll be answering only questions that relate to this month's topic from participants in this live, online conference, as well as questions from members of the breastcancer.org community who couldn't join us tonight. Lymphedema reversible if treated early? Question from Constance: Is arm lymphedema always reversible if treated early? Answers: Nicole Gergich: I think at any stage of lymphedema there's an element of reversibility. We can soften the tissue and we can decongest the limb, especially at the early stages. Dr. Jennifer Sabol: If I can make a comment, as a surgeon I usually tell patents that lymphedema is kind of like blowing up a latex balloon: the more you allow it to stretch out, the harder it is to get back to its original shape. That's why we try very hard to educate patients to look for signs of lymphedema so that we can start treatment early and hopefully get back to the original form of the arm as quickly as possible. Dr. Kathryn Schmitz: I don't know whether the person asking this question intended this thought to come up, but there is a possibility that with the answers that are being given, depending on how they're taken, some women may blame themselves for lymphedema – “Gee, why didn't I do something earlier?” I think there are probably women for whom it's inevitable that their arm is going to enlarge. There are women who, for reasons that are unknown, never do develop lymphedema even if they've had the same treatment. I want to be cautious in saying that it is always preventable, or that we can do a better job with it in every single case when caught early. However, I think that there is ample evidence at this time in the scientific literature that early detection and early treatment are clearly associated with a better outcome and a better clinical course, and that it is less likely if detected early and treated early that lymphedema will become severe. Even with that, there are some women for whom it's completely inevitable that they're going to have a large arm. I don't want anyone reading this thinking that they are to blame for it. -------------------------------------------------------------------------------- What to do for swelling caused by bandaging? Question from PS: Do you have any suggestion for treating hand lymphedema when bandaging and sleeve/glove seem to make it swell more? Answer: Nicole Gergich: That is a complicated situation, as there are so many issues that surround a complicated hand. It can range from the quality of the bandaging that's done, the size of the hand, and the compression class of the garment being used. Many times bandaging and garments become an exercise in strategy and what works for one patient isn't going to work for another. I think just sampling different garments, different bandage strategies, or different alternatives in mechanisms of compression may help. I have thousands of strategies in mind, but I think it's impossible in a conference situation like this to give very specific strategies. There are some good resources for follow-up with bandage strategies or garment strategies. Many of the custom garment companies have advice on constructing garments that could be helpful. Or collaborating with other therapists, if you have a network with other therapists you work with, passing ideas back and forth of what's been helpful, innovative strategies that you can share with one another. -------------------------------------------------------------------------------- Guaranteed way to prevent lymphedema? Question from Doris: Is there any 100%-positive way to prevent lymphedema? Answers: Nicole Gergich: I think the more appropriate way of looking at lymphedema is looking at it in terms of risk reduction. I think that we familiarize ourselves and our patients with how they can reduce their risk of first developing lymphedema. But secondly, if they have lymphedema, how they can reduce their risk of seeing that condition advance? There are excellent evidence based guidelines that have been offered by the National Lymphedema Network, that focus on reducing risk through skin care, prevention of infection, and just taking care of the arm with activity. Dr. Jennifer Sabol: We get a lot of questions from other primary care providers about when it's safe to do things like blood pressure, putting IVs in someone's arm, etc., and there are some perceptions that if the arm hasn't swelled after 1 or 2 years, that it's safe to do these normal medical procedures. I think a lot of patients would like to know your opinion on that. Nicole Gergich: Again, if we look at the literature, it is surprisingly scant in these areas. Venipuncture is one thing; actually dropping an IV is another thing; glucose-monitoring finger sticks is another thing. So 3 forms of skin puncture, just as an example. We don't have the evidence to say one is safer or more detrimental than the other. We do advocate for their patients to keep their skin integrity maintained, so it stands to reason we'd avoid those things on an affected or at-risk limb to avoid an infection. Again, it's a mechanism of risk reduction. However, what we need to understand to answer Dr. Sabol's question is that once the lymphatics have been damaged or removed, they never regrow, so that patient remains at risk for life. So I don't think that we can say that in a period of time that it is safe for us to undertake activities that we know may increase the patient's risk. -------------------------------------------------------------------------------- Swelling worsens without sleeve? Question from Karen: If you have LE and don't wear a compression sleeve 24/7, will your swelling irreversibly worsen over time? Answers: Dr. Kathryn Schmitz: I think it needs to be known that there is at least one therapist out there who's very popular with patients who think asking women to wear compression garments all the time is an unacceptable state of affairs and that more frequent massage-based drainage can do the same thing as wearing a sleeve, perhaps in combination with pumping. I can also say that opinion, from my experience, does appear to be outlying, that most lymphedema therapists recommend the regular use of compression garments. The question of how many hours a day is truly an individual clinical decision. Nicole Gergich: I would add that, if we look at some of the historical work in the literature (I refer specifically to the Casley-Smiths) that lymphedema will progress over time if it's not managed appropriately. So I agree with Dr. Schmitz that it comes down to an individual clinical decision about what is appropriate treatment. Compression garments have been shown to be very effective to maintain limb volume. -------------------------------------------------------------------------------- Still okay to ride exercise bike? Question from Carol: Before several of my lymph nodes were removed due to breast cancer, I used to ride a stationary bike for exercise. Can I still ride it now or will it be too much exercise for my surgical arm? Answers: Dr. Kathryn Schmitz: The answer is you should absolutely ride your stationary bicycle, and it will not be too much for your affected arm. In fact, I would submit, and I hope that Jennifer and Nicole will agree with me – if it's controversial I suppose they'll tell me – that the risk of inactivity poses greater long-term health risks than the risks of being active. I think that there is evidence that weight gain and obesity are associated with worsening of lymphedema. And there is evidence that exercise is effective in avoiding weight gain. Therefore, aerobic exercise in particular may be quite useful in risk management and attenuating worsening of lymphedema. Dr. Jennifer Sabol: I think it's fair to say we all agree 100%. -------------------------------------------------------------------------------- Exercises to prevent lymphedema? Weights okay? Question from Marianne: I'm wondering what exercises can help prevent lymphedema? Can I lift weights at all on the affected arm, even just 5 lbs? Answers: Dr. Kathryn Schmitz: The answer would be yes. You can lift 5 pounds, you can lift 15 pounds, you can lift 100 pounds. The issue is not what you can lift; it's gradually increasing the capacity of the affected limb. You want to increase the amount that you lift gradually enough that the affected limbs have a chance to communicate through symptoms that you've done too much. So if you start by lifting 1 pound and you feel fine, then the next session you try to lift 1-1/2 pounds or 2 pounds and you feel fine after that, and the next time you increase again by 1/2 pound or 1 pound increments. As long as your limb is not changing in any negative way, there is no need for an upper limit on the amount that you can lift. But you do need to build your capacity gradually. I'll use an analogy here: after someone has a heart attack you certainly don't ask them to go out and run a marathon the next week. But there is ample evidence that individuals who have had heart attacks can and indeed do train and successfully complete marathons. They start in cardiac rehabilitation programs and gradually build up capacity of their damaged heart so that they are capable of running faster and longer than the average person. This would hold true for the lymph system as well. Nicole Gergich: I feel very strongly that women who have been given the advice that they should "never lift more than 5 pounds for the rest of their life" should take that advice and throw it out the window. I truly believe that every exercise program is to be individualized. Every patient has the ability to do whatever activity they choose, whatever it is – rock climbing, dragon boat racing – as long as they choose an appropriate mechanism to train and monitor their limb. Dr. Kathryn Schmitz: I will add one thing: something women with lymphedema can't afford to do versus women not at risk can afford to do is to injure the arm due to overactivity. So women who have lymphedema do have to be smart that if they walk away from exercise for some period of time, they must back off and rebuild the limb. Muscle is a “use it or lose it” tissue. So if you stop training because you're taking care of your sick mother or you're busy at work, like any other woman wearing many hats and meeting other needs, you need to be aware of the breaks between exercise sessions and not overextend the limbs after a break. That is key. -------------------------------------------------------------------------------- Breast lymphedema possible? Question from Amy: Does lymphedema only occur in the arm or can it be in the breast as well? Answers: Nicole Gergich: Absolutely! Not only can it be in the breast as well, it can be exclusively in the breast and chest wall, even if it does not appear in the arm. So we need to recognize that breast edema and chest wall edema exist and should be treated. Dr. Jennifer Sabol: As a surgeon, I probably see it more acutely than most and have a more difficult time getting other physicians to acknowledge that there is such an entity as lymphedema of the breast which is actually quite uncomfortable for some patients as well as alarming, because it is difficult to ask for treatment for swollen breasts. I think maybe you can comment on how you manage patients like this. Nicole Gergich: I would say, first of all, recognition is part of the key. I believe anecdotally that I am seeing more frequency of breast and chest wall swelling – lymphedema, if you will – now with the sentinel node biopsy, as we are removing the direct drainage pathway out of the breast. Unfortunately, it is going far underrecognized. Treatment for breast and chest wall lymphedema is analogous to the way we would treat the arm, meaning that the patients would require lymphatic drainage, compression, therapy, exercise, and skin care. Many of these patients will require custom fit or near-custom compression bras. Dr. Kathryn Schmitz: I would say this is an international problem. I was at the Australasian Lymphology Association meeting in Perth in March, and this issue of seeing more breast edema was a theme there. It seems to me that the compression garments and treatments available are not as advanced as they are for arm edema, the compression garments in particular. Nicole Gergich: I would agree with that to an extent. I think there are excellent compression bras that exist. I agree with you that we are as not highly evolved in this area in recognition, treatment, and management as we are with the arms. Dr. Jennifer Sabol: I would add one note of hope, and it is sort of anecdotal. I think this is one of the few times that lymphedema does have a tendency to regress. It's probably due to the acute injury of the radiation therapy. Breast edema does tend to go down over time, though it may not disappear. It is a very slow resolution of the edema and it's almost never complete. I generally tell patients to expect a very slow, ongoing improvement, even over 2 to 3 years after their radiation therapy, until they reach a stable plateau. I'd be curious if you two have found the same sort of better overall prognosis for the breast edema. Nicole Gergich: I typically treat breast lymphedema; I wouldn't expect it to spontaneously resolve itself. I think there is a large cohort out there where we see swelling not only in the breast, but the lateral chest wall and posteriorly in the scapular area, swelling that persists and is identifiably asymmetrical. We cannot expect it to spontaneously decongest in all of our patients. -------------------------------------------------------------------------------- How common is lymphedema from radiation? Question from JJ: What percent of patients who receive radiation treatment to the underarm node region develop lymphedema? Answer: Nicole Gergich: I don't know if we can give an exact percent, but we would assume that if the patient is getting radiation to their underarm that they have positive lymph nodes and have probably had more removed, so their risk according to current research could be as high as 48%. I emphasize the “could be” – it could be as high as 48%. -------------------------------------------------------------------------------- Risk of lymphedema from flying? Question from EMcK: Is it advisable for all patients to wear a sleeve when flying? What if only one or two lymph nodes were removed? Is there a difference between short and long flights? Answer: Nicole Gergich: Again, I think making a blanket statement like “all” or “every” to our patients does not serve them well. I do believe that there is ample anecdotal evidence that there is a shift in fluid when people are exposed to a decreased air pressure for a long period of time. My feet swell when I go to Los Angeles on a flight. So I think everyone's body will respond to that pressure differently. If a patient is to have a compression sleeve for an airplane flight, the garment should be well-fit by a trained therapist, and the patient should be familiar with how to properly wear the garment. -------------------------------------------------------------------------------- How to tell normal swelling from lymphedema? Question from Lyd: How can I tell the difference between the swelling in my arm and breast from radiation (I am 2 months out of treatment) and the signs of lymphedema? Answers: Nicole Gergich: I would say the hallmark sign of lymphedema is an asymmetrical swelling in the tissue that persists over time. We also need to understand that skin changes and tissue changes related to radiation can persist for a long period of time. In fact, inflammation is high in that tissue for up to a minimum of 4 months, and longer term changes can happen for up to 5 years. So to tell the difference in the early stages I agree is difficult, and there's not a specific percent of difference we would say is accurate. But the question I would ask is does the swelling change over time? Do you see the swelling in your arm or breast change from week to week or day to day? Month to month even? Is it gradually improving over time? If it is, I'd say it's related more so to the radiation. Dr. Jennifer Sabol: I tend to agree. I think it's very difficult to decide what is simply treatment radiation change and going to get better. Traditionally, we think of radiation swelling as being within the radiated field, meaning the breast; however, treatment's effect can also impact the lymphatics as they come out of the arm, and during radiation treatment some patients may experience more arm swelling. Again, these changes do subside slowly over time. I think while it's impossible to specifically treat lymphedema during radiation (and Nicole may have a comment about that), symptoms that persist after treatment should be managed aggressively. Nicole Gergich: I think we can certainly treat someone during radiation therapy, although it becomes very difficult. I think the program, though, becomes slightly modified depending on how the tissue is responding to radiation. Certainly, we can stimulate the lymphatic system in its proximal and central and healthy areas, but we would tend to avoid massaging over the radiated field. So it does limit the treatment to some degree. Compression would also be limited during radiation treatment as we need to protect tissue. I think we need to remember that the lymphatics in the underarm drain the tissue of breasts, the chest wall, and the arm on the same side. So even if we don't directly damage the arm or the underarm with radiation, there still can be damage done that impacts the drainage of that entire quadrant. -------------------------------------------------------------------------------- Manicures safe with arm lymphedema? Question from Website Question: Is it safe to get a manicure if you have arm lymphedema? Answer: Nicole Gergich: Absolutely! As long as it's done in a safe manner, and by that I mean protecting the skin integrity. Again, we advise people not to have their cuticles cut and just simply push them back. It's a safe mechanism by which you can protect the skin. I've had patients who take their own sterile supplies to have their manicures done, because they feel more comfortable that way. There's never a never and never an always, that's what I like to say. I think that's very true when you deal with lymphedema. -------------------------------------------------------------------------------- Okay to practice yoga after nodes removed? Question from JSD: I have had 25 lymph nodes removed and radiation to the area. I do yoga regularly (inversions supporting the body with arms and feet, push-ups, etc.). Is this something I should continue if I was doing it during treatment and after? Is it dangerous to continue this? Answers: Dr. Kathryn Schmitz: It's perfectly safe, keep going. Nicole Gergich: And good for you for doing inversions. Dr. Kathryn Schmitz: In general, I think it is important to have women learn to increase the load on the affected limb GRADUALLY. That means that you do positions such as downward dog for a moment the first time, and then increase time over weeks/months, using the same approach with other inverted or upper body intensive poses. -------------------------------------------------------------------------------- Why so few lymphedema therapists? Question from Maire: Why are there so few lymphedema therapists? Is there a standard of care that should inform patients about getting evaluated early on? Answers: Dr. Kathryn Schmitz: There is actually something this audience should know about. There's a difficulty in this field, like nutritionists and exercise trainers, in that there is no current regulation of who calls themselves a lymphedema therapist and who does not. In response to this, the National Lymphedema Network, www. lymphnet.org, has published a physicians’ paper that is easily downloaded on the adequate training of lymphedema therapists. Further, the schools that fulfill those requirements publish their lists of students who have completed and are certified. Unfortunately, that's the best we've got in the United States. I can tell you, they're way beyond us in Australia. Nicole Gergich: And many of the European countries as well. Dr. Jennifer Sabol: I think part of that is there are issues with reimbursement. It's a shame we're not particularly good at reimbursing for lymphedema care in this country. It becomes hard to find therapists who feel passionately about this and want to be well trained. -------------------------------------------------------------------------------- Shoulder bags okay to wear? Question from Rose-5: Is it okay to wear a shoulder strap handbag on the affected arm? Also, would activities such as painting walls cause damage or be detrimental? Answer: Dr. Kathryn Schmitz: This question comes back to the issue of overuse and understanding what overuse is for you individually. If your shoulder bag requires more of your limb than it can handle and your arm feels tired and stressed after wearing it, it's too much. Get a smaller bag. If your limb feels okay, it's fine. If your maximal capacity of the affected limb is a 10 and any activity – not just carrying a shoulder bag – requires 9.5 out of 10, that's probably too much. So rather than say you can never carry that bag again, go do some exercise so that your capacity becomes a 15 and carrying a bag that requires 9.5 isn't such a big deal any more. -------------------------------------------------------------------------------- Exercises for lymphedema? Wear compression garment forever? Question from Kay: I developed lymphedema in my left arm and my left breast (trunk area). Are there any exercises that I should be doing on a regular basis? Do I need to wear my Belisse compression bra for the rest of my life, as well as the arm sleeve? What precautions do I need to be aware of? Thank you and God bless! Answer: Nicole Gergich: I think the precautions have been well outlined up to this point, as far as precaution with activity and exercise, lifting, etc. Indeed, there's no restriction; you just need to be cautious about completing those activities to the best of your abilities. As far as wearing compression garments for the rest of one's life, I think that is different for every patient. You will probably need some degree of compression on the chest wall. It's hard to say if that's every day, all day, and the same goes for the arm sleeve. I think everyone is different and as we learn our limbs, we learn our breasts also, and how much compression we need to maintain the swelling to a degree that's comfortable for us. -------------------------------------------------------------------------------- Exercises to cure lymphedema? Question from SWoods: Are there exercises that one can do to make lymphedema go away? Answers: Dr. Kathryn Schmitz: No. Nicole Gergich: No, but I would say when exercises are done in the context of a complete decongestive therapy program, they can maximize limb decongestion. Once we have lymphedema, it never goes away. That is vital for people to understand. -------------------------------------------------------------------------------- Research on drugs to increase lymph flow? Question from Gabriela: Is there any research being done to develop pharmaceutical solutions (i.e. drugs) to increasing lymphatic flow? Answers: Dr. Kathryn Schmitz: I am aware of research that is likely at least a decade away. It is at the point of early discovery of targets that could lead to the development of a drug. Dr. Jennifer Sabol: I don't know of any in the present right now. I know several compounds have been used in the past anecdotally, and none have proven to be either effective or necessarily safe, even. -------------------------------------------------------------------------------- Okay to ignore fluid build-up on elbow? Question from Dane: There is always a little bit of build up of fluid on my arm, around the elbow area. This has been present for over 5 years. It does not worry me, so am I correct in ignoring it? Answers: Nicole Gergich: No! Dr. Kathryn Schmitz: This is one of those questions that I worry about, because we don't want anyone reading this or looking at the transcript to walk away freaked out unnecessarily. That said, Nicole's No! is well taken. We've known for a long time that early intervention and management is effective at preventing or attenuating worsening of lymphedema. At the very least, monitoring that limb is worth pursuing. Nicole Gergich: Your arm is telling you a story right now. It is telling you that there is a fluid congestion; it is telling you that it is likely related to lymphatic overload. Even though it hasn't progressed, it doesn't mean there's not still a risk, especially for infection. It may not bother you and it may not ever get worse, but because it exists and it's there, it's your limb telling you already that it's a little bit too stressed. You have to heed that little bit of a warning, so just keep an eye on it. -------------------------------------------------------------------------------- Does computer work affect lymphedema? Question from Georgia: I use the computer for 99% of my work day. Will this affect my arm? Answers: Dr. Jennifer Sabol: It's sort of like using a computer and the development of carpal tunnel – some people will develop carpal tunnel but some people will not. Only time and trial and error will tell you if you're going to develop lymphedema in that situation. I think my only suggestion would be to make sure your work station is ergonometrically (physically safely) positioned – the seating and desktop area. Nicole Gergich: Again, if you are someone who's been using their computer for 99% of your work day for years and years, your arm is probably in tune with that level of activity. -------------------------------------------------------------------------------- Shaving and lymphedema risk? Question from Ruth: What about shaving? I really hate the electric razor! Answer: Nicole Gergich: This just goes back to skin care. The less opportunity we give for bacteria to enter our skin with nicks and cuts from shaving, the less exposed we are and potentially the healthier the limb will be. Again, that's not to say nicks and cuts don't happen, and bugs will certainly bite. So if these small punctures to the skin do happen, we take care of them with antibiotic ointment and prevent them from becoming infected. -------------------------------------------------------------------------------- How to participate in lymphedema research? Question from Sue K956: How can one participate in a research project for lymphedema? Answer: Dr. Kathryn Schmitz: I would direct you to www.oncolink.org. That's a fantastic resource for finding about research being done in survivors and patients. I am in the process of trying to disseminate the results of a large study about exercise and lymphedema. It's difficult. -------------------------------------------------------------------------------- Compression sleeves and flying increase lymphedema risk? Question from MELB: My therapist says if you've never had lymphedema, wearing a compression sleeve on a plane will actually increase the risk of developing lymphedema. She says there is already compression in the plane, and adding even more compression with a sleeve will be way too much on a compromised arm. Is there formal study evidence showing anything to support either side of the flight controversy? Answer: Dr. Kathryn Schmitz: Yes, I can answer this. I love it when you go to a conference and you hear something and can tell someone about it. Sandi Hayes in Australia has done a small study, and she's planning on repeating it larger. She asked people to get measured before and after an airplane flight, and she found no effect. She's planning on repeating on a trans-Pacific flight from Sydney to San Francisco to confirm cross- continent flights. I will also comment that I think the reality – given that lymphedema garments are not often covered by third party payers, need to be fitted individually, and need to be replaced every 6 months – of burdening a woman who does not currently have lymphedema with a non-covered visit to a lymphedema therapist and the several hundred dollars for a garment every 6 months, is overkill. I'll also say that in light of this, it's clear from my interaction with women that they take this advice and translate it into putting on poorly fitting compression garments or off-the-shelf Ace bandages, which indeed could do more harm than good. -------------------------------------------------------------------------------- How to respond to lymphedema emergencies? Question from Kris: Thanks so much for sharing your expertise with us tonight. Can you talk a bit about lymphedema emergencies and how/when to respond? Answers: Nicole Gergich: Great question! Dr. Kathryn Schmitz: There was a woman advocate survivor with lymphedema at the conference in Australia who regularly developed cellulitis and finds herself talking to doctors to try to get a prescription for antibiotics in remote areas of Australia. It's a difficult situation for her. Her response has been to have a script for antibiotics on her person at all times. That's one issue: having cellulitis and needing antibiotics immediately. I think it's inexcusable for physicians not to have that available to their patients if they have recurring cellulitis. Nicole Gergich: I think we should define what an infection looks like for those who have never had one: rapid exacerbation of swelling in their arm, redness to the tissue, it will be warm to the touch, and it's typically painful. If a patient's limb or chest wall exhibits these signs they should proceed directly to get medical attention, because a cellulitic infection can first of all bring on lymphedema in someone who's never had lymphedema before. And secondly, it will spread very rapidly as the protein-rich fluid is a culture for bacteria. So I agree with Dr. Schmitz’s comments – patients need to recognize and respond quickly. If they're familiar with infections, if they've had recurrent infections, they should have access to antibiotics. Because Murphy's Law is that Friday night, 10pm, the redness and pain starts in their limb and having access to antibiotics prevents them the trip to the emergency room. It enables them to treat without having a seriously exacerbating situation. Dr. Jennifer Sabol: One thing I would add is that, while sometimes you can get a pink tinge to a swollen limb, patients that have true cellulitis generally feel overall ill. They have a general sense of fever, chills, aches – much like they have the flu and the onset is fairly rapid. I agree it's never at a convenient time. So I encourage a lot of my patients if they're traveling outside of the area to simply fill a prescription and take it with them if they've had recurring episodes. -------------------------------------------------------------------------------- Good news for lymphedema patients? Question from MsMadelyn: Reading this could leave someone facing lymphedema (or its possibility) feeling a little hopeless and helpless. So is there any good news about improvements in the future through research or improved methods? Answers: Dr. Kathryn Schmitz: There's already been good news. The first good news is that we're no longer ripping all the underarm nodes out of women. There was a time, less than 10 years ago, when it was common to remove all of the nodes under the arm, and the rate of lymphedema was higher. So already, we've cut the rate of lymphedema in half or more by the introduction of sentinel lymph node surgery. There has been a lot of recent research that will clarify that women do not need to be as restricted as previously thought in their activities if they have lymphedema. Nicole Gergich: We're also training more and more therapists every year to become more specialized in lymphedema management, and those therapists are telling the world the fact that there is treatment available for lymphedema. A decade ago we used to tell women they had to live with lymphedema, and we have novel interventions today. Dr. Jennifer Sabol: I have to say from a surgery standpoint, I've seen dramatic decreases again with the rate of lymphedema thanks to sentinel node biopsies. But one of the best improvements I've seen is the acknowledgment by the physical therapists we're using that it's not a question of trying to limit someone's activity so this doesn't happen. I now see more therapists asking their patients what they want to do in their life, such as water-skiing or climbing a mountain, and then finding innovative ways to help them get there. -------------------------------------------------------------------------------- ------------------------ breastcancer.org: Thanks for being with us this evening. We hope the support and information you've gotten here tonight will help you discuss some of these issues with your doctor and make the best choices for YOU. We also look forward to hearing from you at future Ask- the-Expert Online Conferences right here at breastcancer.org. --------------------------------------------------------------------------------------------------------- -- Feet Hurt? Stop Wearing Shoes Need a little mercy for your sole? Khaled Desouki "Everyone who wears shoes walks wrong," says Adam Sternbergh, who wrote about shoes and human feet for New York magazine. AFP/Getty Images The Bryant Park Project, April 22, 2008 · It took 4 million years of evolution to perfect the foot, and humans have been wrecking that perfection with every step since they first donned shoes, New York magazine's Adam Sternbergh says. "Everyone who wears shoes walks wrong," he says, echoing the headline of his recent article, "You Walk Wrong." Sternbergh calls the ubiquity of footwear a "conspiracy of idiocy." He points out the probability that at no point did any shoemaker say, "Let's design something that works with your foot." In the Middle Ages, for example, people began wearing shoes with higher heels to avoid stepping in other people's excrement. Today, high heels are considered sexy. Whatever their reasons for wearing the shoes they wear, people don't usually consider whether a shoe actually works with their foot, he says. The human foot works pretty well on its own, Sternbergh says, and it doesn't need a lifetime of help from shoes. He explains the basic illogic of footwear by comparing the concept to a perpetual cast. "Imagine if someone put a cast on your arm when you were 3 years old and you never took it off," he says. "Your arm would stop working. That's kind of what's happened with our feet." Sternbergh cites a 1940s study of barefoot rickshaw drivers in India. Scientists found that the drivers had unusually healthy feet. Sternbergh says subsequent evidence supports the conclusion that feet don't need shoes. Why are shoes on virtually every foot, then? Sternbergh says the rationale that most urban and suburban people use is that the ground is hard and our feet need the cushioning of footwear. "But in many places in the world, the ground is quite hard," he says. "[Our ancestors] were able to absorb the shock." Sternbergh concedes that in most settings, some form of foot covering makes sense. "I'm not going to convince anyone to walk barefoot," he says, acknowledging that he continues to wear shoes as a bulwark against glass, grime and gross things. He may still wear shoes, but Sternbergh has switched to a model from England called the Vivo Barefoot from the Clark shoe family. Galahad Clark, son of the inventor of the Wallabee — a particularly successful, if traditional, shoe — helped develop the Vivo Barefoot. Sternbergh says the shoe is basically a slipper with a Kevlar sole, to prevent puncturing. "They kill your heels," he says. "A traditional shoe advocate would say you need to switch back to sneakers that have a big cushiony heel." But a barefoot-walking advocate would say, "You're walking wrong," Sternbergh says. He asked Clark for advice or instruction, but Clark said walking in the shoe is instinctual. "You'll find that your walk starts to change," Sternbergh says. "You land on your heel, but it's a much softer landing. ... A traditional shoe with a lot of cushioning is designed to allow you to walk with the bad habits that you have because you've been wearing shoes all your life." For those who cling to their typical footwear, Sternbergh is sympathetic. "Shoes perpetuate shoes," he says, referring to the cycle of coddled feet forever needing high-tech --------------------------------------------------------------- MAY 2008 LYMPHEDEMA IN THE NEWS Lymphedema treatments There may be no cure for lymphedema, but Stacea Boss, a physical therapist at the Lymphedema Clinic at Reading Hospital, said there are effective treatments. "Once you have it, you always have it," Boss said. "It’s going to be an inconvenience, but you can reach a point where you need to just maintain the treatment." Boss said the incidence of lymphedema has been well-researched in breast cancer patients (where it usually affects an arm), but there aren’t as good stats for other types of cancer. For breast cancer the incidence of this side effect is somewhere between 20 and 30 percent, Boss said. Because it isn’t as well documented in gynecological or groin cancers (where it usually affects the abdomen and legs), Boss said some of those patients are surprised when it happens. "They are shocked," Boss said. "Breast cancer survivors have really taken it on their shoulders to make sure people understand more about it, but that hasn’t happened with other cancers." Boss said treatment is effective for all affected limbs, although lymphedema in the legs can be more difficult to control. ---------------------------------------------------------------------------------------------- Cancer Centers of North Carolina Receives Prestigious Accreditation RALEIGH, N.C., May 14 /PRNewswire/ -- Cancer Centers of North Carolina's diagnostic imaging service has been awarded a three-year term of accreditation as the result of a recent survey by the American College of Radiology (ACR). Radiation oncologists Dr. John F. Reilly and Dr. K. Kolby Sidhu lead the practice's radiation oncology program, which provides patients with state-of-the-art diagnostic and therapeutic radiology services, including Computed Tomography (CT) and Intensity Modulated Radiation Therapy (IMRT). "We are thrilled to receive the ACR's accreditation because it signals to the community that our patients and our future patients receive unparalleled, cutting-edge cancer care services. This reflects our commitment to excellence and is a significant validation from our national peers and colleagues," said Dr. Reilly. Radiation oncology is the medical use of ionizing radiation as part of cancer treatment to eradicate cancer cells. Physicians can use it as primary therapy, but it is also frequently combined with surgery, chemotherapy and/or hormone therapy. Computed Tomography (CT) scanning is the use of radiation to accurately visualize and evaluate cancerous tumors anywhere in the body. The ACR, headquartered in Reston, Va., awards accreditation to facilities for the achievement of high practice standards after a peer-review evaluation of the practice. Nationally board-certified physicians and medical physicists who are experts in the field conduct the evaluations. They assess the qualifications of the personnel and the adequacy of facility equipment. The surveyors report their findings to the ACR's Committee on Accreditation, which subsequently provides the practice with a comprehensive report. The ACR is a national organization serving more than 32,000 diagnostic and interventional radiologists, radiation oncologists and nuclear medicine and medical physicists with programs focusing on the practice of medical imaging and radiation oncology and the delivery of comprehensive health care services. About Cancer Centers of North Carolina Cancer Centers of North Carolina (CCNC) has been providing comprehensive cancer care and hematology services in the Greater Triangle area since 1979. Beginning as a single physician practice, originally named Raleigh Hematology Oncology, CCNC has grown to include a physician staff of 14 medical oncologists, two radiation oncologists, and the area's only head and neck surgical oncologist. The practice, which now offers services in five locations throughout the area, provides advanced, state-of-the-art diagnostic and therapeutic services, including administration of chemotherapy, biologic and targeted therapies, Computed Tomography (CT), Intensity Modulated Radiation Therapy (IMRT), laboratory and pharmacy services, and an extensive clinical trials program connecting patients to leading cancer investigators around the country. Services are provided in the context of a pleasant, convenient, community-based outpatient setting, where the focus is on patients and their families. CCNC brings the best of medical science and cancer care support services together in one organization, offering nutrition counseling, lymphedema services, physical therapy consultation and fitness programs, social services, stress management, support groups, social services and financial counseling. Practice sites are located in Raleigh, Northern Wake County, Cary, Clayton and Dunn. For information, call (919)-781-7070 or visit SOURCE Cancer Centers of North Carolina "Because of gravity you are more likely to swell," Boss said. She also said even well-managed cases can flare up when patients have been on their feet for a long time, or in the summertime. "Heat takes a toll," she said. "And some patients I have treated and done beautifully will flare." Flares are one problem, but infection is actually a more serious complication of lymphedema as the affected limb can easily become infected due to the skin and tissue being compromised by the swelling. In addition the lymph fluid contains toxins that should be flushed by the lymphatic system but instead are pooling in the tissue. While quality-of-life issues are difficult, an infection in a swollen limb can be life-threatening, so management is essential. Boss said she also suggests her clients drink lots of water and try to maintain a low-salt diet in addition to the wrapping and massage. She also suggests yoga, breathing exercises and range-of-motion exercises. Acupuncture can offer some relief to patients who research to make sure the practitioner uses sterile equipment in a sterile environment. "Exercise and yoga enhance the pumping mechanism in the body to help move the fluid," she said. "We encourage them to do it throughout the day." While there is no cure for lymphedema, Boss said researchers are working on ways to perform surgeries and radiation with less damage to the lymphatic system. "They are trying to find ways to minimize the damage," she said. 5/13/2008 Living with lymphedema The side effect of her cancer treatment has left Barbara Starr’s leg swollen to the point where neither her clothes nor her shoes fit. There’s no cure for the disorder, but the Hamburg-area woman is trying to make the best of a bad situation. By Tracy Rasmussen Reading Eagle Correspondent Barbara Starr’s cancer may be cured, but the fight for the quality of her life continues. The surgeries and radiation that destroyed the cancers in her uterus and bladder took the healthy cells of her lymphatic system too, leaving her with a leg so swollen neither her clothes nor her shoes fit. And there is no cure. Lymphedema is a side effect of cancer surgery that occurs when the lymphatic system is compromised either through the removal of lymph nodes or through radiation. While it is generally more common after breast cancer treatment, it’s also a side effect of gynecological surgeries, where the lymph nodes in the groin are affected. "When I came out of my surgery everyone commented on how healthy and strong I looked," said Starr, 67, of the Hamburg area, who also went through chemotherapy and radiation therapy in 2006. "The surgery was in February, and then I went through megadoses of radiation and chemotherapy until September." In the summer of 2007 Starr said she noticed that her right leg was beginning to swell. "I was getting acupuncture because of it and it went down," she said. "That spontaneously resolved." However late in the summer she took a vacation to Peru, which required a long plane ride. Unbeknownst to Starr, plane travel is often a trigger for lymphedema, stressing an already compromised lymphatic system. "When I got off the plane my left leg was swollen," Starr said. "And it’s never gone down since then." In fact her leg sometimes gets so swollen that the normally petite size 8 or 10 had to shop for plus sizes, just to get pants that would fit around her abdomen and leg. She still can’t wear the two pairs of shoes she had made for her in Peru and doubts she ever will. "Thank God for Crocs," she said. "They’re the only thing that I can wear." Physical therapy regimen Upon returning to the states, Starr was diagnosed with lymphedema and began a regimen of physical therapy that was designed to help her body drain the fluid that was accumulating in her leg. Because she had some lymph nodes removed and others damaged, the fluids and toxins that normally circulate through the body to be processed through the lymphatic system never get moving. Instead they pool, infuse the tissue and cause the swelling. Physical therapy uses a specific type of massage to push the fluid past the damaged portion of the system to a place where it can be circulated back into the lymphatic system. The massage is a gentle kneading that starts at Starr’s feet and works the fluids up to where it can hitch a ride through the healthy portion of the system. Once the leg has been flushed of fluid, it needs to be wrapped tightly to keep the swelling down. Yet no matter what she does, the swelling in Starr’s leg returns. "The bandages look like ace bandages but they don’t have any stretch in them," Starr said. "Every single toe is wrapped and (the therapist) would put pads at my ankles bone and around my calf and wrap over them. You can imagine how thick it is." After several months of that, Starr said it was clear the treatment was not enough. "None of that was really working for me," Starr said. "The swelling continued." Now she hooks herself up to a pump every night or when she’s relaxing and sleeps while it gently massages the fluid from her leg. "It’s finally allowed the fluid to pass for me," Starr said. "But it’s temporary. I have to do it every single day." Once she’s done with the machine she re-wraps her leg and gets on with her day. "The only time my leg is unwrapped is the time it takes to take a shower," she said. Starr knows there is no cure for the disorder, but she’s looking forward to using a new type of tight leg stocking that will do basically the same thing as the wrapping, but is easier to apply. But mostly, she’s working on accepting the way her life has changed over the past year and the way she can recover. Extraordinary attitude First, her attitude is extraordinary. She’s learned to cope and make the best of the situation, despite the challenges that keep coming. A few weeks ago her foot caught on the deck outside her home and she fell, breaking her wrist. "My foot is heavier now and I don’t walk the same way," she said. "It’s hard to bend my knee. I was wearing a new pair of shoes and I wasn’t used to them, so I fell." The purple cast on her arm makes it even more difficult to wrap her leg and get around, but she’s trying to make the best of it and is grateful for the health she enjoyed prior to cancer. Starr was always very active, she said. She’s a vegetarian who enjoys hiking and biking and being active. It’s that basic health, she said, that has allowed her to get as far as she has. She tries her best to have her good attitude cancel out her bad leg. "Gardening is difficult," she said, as an example. "So I do it when I can. I go out there and pick a couple of weeds. And I’m trying to get back into yoga. So it’s not the end. You just need to adjust." Starr’s way of adjusting is to try and give back to others. She’s working on starting a branch of the Wellness Community in the Hamburg area, and she’s hoping to be able to help others with the same affliction through yoga and massage. "I try to stay in the moment and live right now," she said. "My life is very different and I really feel my mortality now. But I want to give back, so I’m going to. And I’m hoping that some day there will be a miracle cure." ====================================================================== ==================== Faxton-St. Luke’s program receives grant -------------------------------------------------------------------------------- Observer-Dispatch Posted May 15, 2008 @ 11:10 AM -------------------------------------------------------------------------------- Faxton-St. Luke’s Healthcare announces the Lymphedema Treatment and Management Program at The Regional Rehabilitation Center has been awarded a $30,000 grant from the Central New York Affiliate of Susan G. Komen for the Cure. The grant will be used to help breast cancer survivors purchase necessities such as bandaging supplies, compression arm sleeves and gloves. The money will also be used towards educating the therapists who treat breast cancer and lymphedema with the most current and state-of the-art technology. For more information, please contact the Lymphedema Treatment and Management Program at (315) 624-5400. .. Tina Budde Applause to the Susan Komen for the Cure foundation. They have given so much to help not only cancer patients but lymphedema as well. There is hope for lymphedema patients. With all the research monies given out, we are seeing a mass explosion of possible treatment options for the future emerging such as lymph node transplants. Also there is technology, Impedimed has a machine that can detect stage 0 lymphedema, thus treating it before it becomes really noticeable. That can help primary lymphedema patients' children from ever developing full blown lymphedema with early intervention and change quality of lives for not only them but breast cancer survivors. http://health.groups.yahoo.com/group/lymphland/ Any lymphedema patients, feel free to join my support group. We keep up to date on all aspects of the condition. Sincerely, Tina Budde Lymphland International Lymphedema Online and Lymphland.com --------------------------------------------------------------------------------------- Routine Screening Of Breast Cancer Patients For Symptoms Of Sub-Clinical Lymphoedema Leads To Better Clinical Outcomes Main Category: Breast Cancer Article Date: 20 May 2008 - 4:00 PDT Get the Facts on Breast Cancer. Pictures, Symptoms and Treatments. MedicalHealthData.info Breast Cancer Photos Seek Out Causes, Symptoms, And Treatments For Breast Cancer. HealthWellnessGuides.info Breast cancer patients should undergo routine surveillance for sub-clinical lymphoedema, concludes a study published in Cancer. The study, which was conducted in the US, showed that compression garments introduced early in the course of lymphoedema can be used to effectively treat the sub clinical condition. Lymphoedema is an abnormal buildup of fluid, most often in the arms or legs; that occurs when lymph vessels or nodes have been damaged or removed. This occurs after breast cancer surgery or lymph node biopsy where removal of lymph nodes and vessels from under the arm changes the way lymph fluid flows. Breast cancer related lymphoedema is a chronic condition - estimated to affect 33 to 47 % of women following axillary lymph node dissection and 4 to 17 % after sentinel node biopsy. It is a progressive condition that diminishes a womanR! 17;s quality of life and contributes to impairment in the range of movements, loss of strength and limits every day activities, such as lifting and reaching. It has previously been reported that changes in interstitial tissue congestion occur before limb swelling becomes visible. Furthermore, it was suggested that earlier detection might result in fewer long term complications. Stout Gergich and colleagues, from the National Naval Medical Center ( Bethesda, Maryland, USA) set about investigating the efficacy of surveillance in patients with early stage breast cancer. The investigators hypothesized that on diagnosis of sub-clinical lymphoedema, a light grade compression garment worn daily would be sufficient to alleviate the problem. Between 2001 and 2006 all women with newly diagnosed unilateral early stage breast cancer (stage I- III) were screened by a physical therapist prior to surgery to determine eligibility. Patients were excluded from the study if they had a previous history of breast cancer, bilateral breast cancer or if they had suffered severe trauma or surgery to their upper limb. For the 196 women meeting the study criteria, limb volume was measured pre operatively and at three - month intervals following surgery using a Perometer. The Perometer is a sensitive and standardized device using infrared optoelectronic technology to detect and quantify limb volume changes. If the upper limb volume increased by greater than 3% compared with the preoperative volume, then a diagnosis of lymphoedema was made. Altogether 43 women were found to have lymphoedema and offered early intervention with a ready made 20 to 30 mmHg compression sleeve that was fitted by a physical therapist and worn for four weeks. Upon reduction of lymphoedema women were advised to wear the garment during periods of strenuous activity, if they experienced symptoms of heaviness or if they saw visible swelling. Results show that the average time to onset of lymphoedema symptoms was 6.9 months after the operation. The mean affected limb volume increase was 83 mL (±119 mL; 6.5% ± 9.9%) at lymphoedema onset (P = .005) compared with the baseline measurement prior to the operation. After intervention with the compression sleeve, a statistically significant mean 48 mL (±103 mL; 4.1% ± 8.8%) volume decrease was achieved (P < .0001). The mean duration of the intervention was 4.4 weeks (±2.9 weeks), with volume reduction maintained at the follow up of 4.8 months. While the standard of care for treating and managing clinically apparent lymphoedema is well established, write the authors, there is no standard for the treatment of early-stage, subclinical lymphoedema. "A new classification system is needed to recognize subclinical lymphoedema and encourage early intervention to diminish the negative functional, cosmetic, and psychosocial consequences of lymphoedema. On the basis of our findings, we believe that a more sensitive threshold for diagnosing lymphoedema is warranted and can be quantified by using optoelectronic imaging technologies," conclude the authors. Few clinical sites currently have access to optoelectronic measurement technology, concede the authors, but suggest that other assessment tools such as water displacement, bioelectrical impedance analysis, and circumferential girth measurements could all be used to diagnose sub clinical lymphoedema. Preoperative assessment enables the early diagnosis and successful treatment of lymphedema. Stout Gergich N L, Pfalzer L A, McGarvey C, Springer B, Gerber L H, Soballe P. Cancer (online 21 Apri1, 2008, DOI 10.1002/cncr.23494) Cancer Research Summaries are overviews of important cancer research findings that have been reported in leading cancer publications. The Cancer Research Summaries are provided by the Cancer Media Service (CMS) in collaboration with Nature Clinical Practice Oncology. All previous Cancer Research Summaries can be viewed here. This summary can be reproduced without permission. If reproduced please include the following acknowledgement: "This summary is provided by the European School of Oncology's Cancer Media Service." http://www.cancerworld.org/mediaservice ====================================================================== ============== Nurse Addresses Lymphedema In Breast Cancer Patients And Survivors Main Category: Breast Cancer Article Date: 18 May 2008 - 0:00 PDT Breast Cancer Treatments A poster session presented by The University of Texas M. D. Anderson Cancer Center at the Oncology Nurses Society 33rd Annual Congress, found that early nursing intervention and implementation of effective strategies can lead to a decrease in the incidence of lymphedema, better management of chronic lymphedema and improved quality of life in breast cancer patients. The literature review, led by Mattie J. Sennett McDowell, RN, BSN, a research nurse in the Department of Breast Medical Oncology at M. D. Anderson, examined 20 years of data about the prevention, management and care of upper extremity lymphedema (ULE), or lymphedema that occurs in the arms, in breast cancer patients. The goal of the review was to identify a comprehensive list of current evidenced- based strategies that nurses and hospitals can use in caring for their patients. "Women are living longer as breast cancer treatments get better, but at the same time, they face more devastating side effects like lymphedema," McDowell said. "So many women present with the symptoms, yet it is understudied and not well understood. More can to be done to proactively recognize and address lymphedema in breast cancer patients." ULE is an often a distressing and debilitating side effect of breast cancer treatment in which protein-rich fluid in the tissue of the arms accumulates and obstructs the lymph vessels. According to the National Lymphedema Network, approximately 15 to 20 percent of all breast cancer patients are affected by ULE. Its development can be triggered by breast cancer diagnostic procedures, radiation, surgery or environmental factors. It also can can occur immediately after treatment or many years down the road. ULE, which can make simple tasks such as picking up children, getting dressed or exercising painful, has a detrimental impact on the patient's quality of life. According to the literature, effective strategies to address lymphedema included early identification of at- risk patients through enhanced assessment techniques, monitoring, standardizing at-risk assessment tools and increased awareness of lymphedema through educational efforts of the health care team. The studies noted that increased awareness through educational forums, patient-nurse learning modules, and increasing the number of research studies focusing on ULE are vital in addressing this problem. McDowell, who is dedicated to the study, prevention and management of ULE after a breast cancer patient died from significant disease progression, complicated by advanced, unmanageable lymphedema, said, "This research is centered on what is important to the patient and their quality of life after treatment. Nurses are on the frontline and may hold the key in proactively preventing lymphedema in many patients by educating them about triggers and symptoms, continual and specific lymphedema assessments during each visit and pursuing research in this area." At M. D. Anderson, nurses and patient care teams have implemented several strategies to educate breast cancer patients about lymphedema and treat it aggressively. One such strategy is having a nurse and physician present information via discussion and prepared handouts before women undergo surgery. Additionally, all women are assessed for lymphedema during treatment and at follow-up visits. M. D. Anderson's multidisciplinary care team also offers comprehensive support and collaboration from prevention of the sequelae to advanced physical therapy for those with lymphedema. McDowell plans to develop further research studies examining the evidenced-based practices for ULE identified in this study, with the end-goal of developing a standard set of recommendations. More information on the causes and symptoms of lymphedema, risk reduction strategies and recommended treatment are provided online at M. D. Anderson's Rehabilitation Services Lymphedema homepage or by logging onto the National Lymphedema Network Web site. About M. D. Anderson The University of Texas M. D. Anderson Cancer Center in Houston ranks as one of the world's most respected centers focused on cancer patient care, research, education and prevention. M. D. Anderson is one of only 39 Comprehensive Cancer Centers designated by the National Cancer Institute. For five of the past eight years, M. D. Anderson has ranked No. 1 in cancer care in "America's Best Hospitals," a survey published annually in U.S. News and World Report. About Nursing at M. D. Anderson Nursing is a pillar in M. D. Anderson;s worldwide reputation for cancer care, research, education and prevention. Nearly 2500 professional nurses work in M. D. Anderson's clinics and hospital as direct care providers, research nurses, advanced practice nurses, case managers, educators and many other roles. M. D. Anderson is recognized internationally as a Magnet institution. University of Texas M. D. Anderson Cancer Center 1515 Holcombe Blvd., Box 229 Houston, TX 77030 United States ----------------------------------------------------------------------------------------- Our World: Survivor By MICHELLE CASSEL (Contact) 6:03 p.m., Sunday, May 18, 2008 MICHELLE CASSEL / Staff Maria Mason (left) kisses her mother Dolores Mason after they crossed the finish line at the Danskin Womens Triathlon in Orlando on Mother's Day May 11th. FYI: May 19, 2008 Calif. museum hosts China’s terra cotta warriors Local project to turn 'Cinderella' yard into example for future landscapes Share and Enjoy [?] There are many ways to die, Dolores Mason told her two grandchildren 12 years ago. You could get hit by a car. You could fall down a flight of stairs. But the breast cancer diagnosis Mason had just received? “I’m not going to die from this, you understand,” Mason told them. At age 66, Mason has now fought through her cancer, vertigo, obesity, depression, diabetes and lymphedema. Her health problems are ongoing, as is her will to overcome them. I met Mason in December on the ninth green of the Merrill Lynch Shootout, where she was working as a volunteer. She was eager to discuss an unusual birthday gift she had just received from her three children. Her children had hired a retired triathlon coach named Mary Ann Wallace to train her to race in the Danskin Women’s Triathlon at Walt Disney World on Mother’s Day. The triathlon is a sprint triathlon consisting of a .75-mile swim, 9-mile bike ride and 2-mile run through Disney’s Magic Kingdom. The event raises funds and helps bring awareness for breast cancer. Mason was incredulous. “I can’t do this, I’m too old!” she told her daughter Maria Mason, a triathlon trainer living in New York City. “Mom, you don’t have to worry about it. I trained a woman that was 55 and she finished. I know you can do it.” Maria told her mother. Later Maria would join the race to support her mother. “She’s always looking out for the rest of us,” said Maria, who finished right behind her mother in the May race. Mom at 971 out of a field of 1,165 and Maria at 972. “She doesn’t do anything that really makes her feel good about herself and this was something that I saw was a chance to do that.” For the next five months I followed Dolores, filming her push through the physical and emotional training Mary Ann had set forth. Wallace met with Mason twice a week at Lowdermilk Park to work on swimming, biking and running. On her days off, Mason would continue to train and do exercises assigned by Wallace. That meant roughly nine hours a week to prepare for the triathlon. I asked Dolores what kept her motivated. “I want to do it for all the people that have breast cancer or have had breast cancer,” she said. “I also want to do it for my children, my husband and myself. To prove to myself that I can do something.” http://www.naplesnews.com/news/2008/may/18/our-world-survivor/ -------- It seems like he changed after that shot' By JO CIAVAGLIA Bucks County Courier Times Like a good doctor's wife, Melissa Miller vaccinated her firstborn son, Sam. She wishes now she wasn't so good. Not long after Sam had his mumps-measles-rubella and other routine childhood shots, the toddler developed bad gastrointestinal problems, Miller said. He stopped talking, stopped making eye contact, he stopped being Sam. By the age of 2, the family finally learned what was wrong. Sam, now 8, had autism, a developmental disability that impairs a person's ability to communicate, socialize and form relationships. The autism diagnosis was upsetting enough. Then further medical tests revealed something more disturbing. Sam's blood had high levels of heavy metals, such as lead and mercury, which are found in vaccines. Could it be a coincidence? Miller doesn't think so. She isn't alone in her belief either, despite a lack of scientific proof linking childhood vaccines with autism and other health disorders. Today more than 10,000 people are expected to attend a vaccine safety rally in Washington, D.C. Celebrities such as actors Jenny McCarthy and Jim Carrey plan to attend. McCarthy has a 5-year-old son with autism. Miller, a Northampton resident, organized a charter bus, which was expected to leave early this morning with about 50 Bucks County residents headed for the “Green Our Vaccine” march in the nation's capital. The event is part of a campaign to convince Congress to re-enact legislation that would eliminate mercury and other toxins from vaccines and encourage national health agencies to reassess the childhood vaccine schedule. Organizers also want the government to extend the statute of limitations to allow all children affected by what they call vaccine-induced autism to file in the National Vaccine Injury Compensation program. Vaccine safety supporters contend that toxins used as vaccine preservatives contribute to brain disorders such as autism and Attention Deficit Disorder, and other chronic health conditions such as asthma and arthritis, which are increasingly diagnosed in children. In 2001, amid growing safety concerns, the vaccine additive Thimerosal, which contained mercury, was removed from all routine childhood vaccines, though some flu shots still contain it. Last month the United States Court of Federal Claims began hearings on whether Thimerosal caused children to develop autism. The court is considering whether the government should compensate the parents of roughly 4,800 children with autism. NO EVIDENCE Still, no credible scientific link between vaccines and autism has been found despite major government, academic and public health studies, and public health experts worry the anti-vaccine trend could lead to a re-emergence of illnesses such as measles and whooping cough. The medical community believes the dramatic increase in autism diagnosis over the last 20 years is related to earlier diagnosis, more comprehensive screening, better public awareness and a broader definition of the disorder. In the past, people with autism disorders were likely misdiagnosed as mentally retarded or emotionally disturbed, many doctors believe. The Centers for Disease Control and Prevention recommends that children age 6 and younger be vaccinated against 15 diseases, including meningitis for high-risk kids and an annual flu shot. The Bucks County Health Department's childhood vaccination program administers about 30 immunizations during that time span, said Barbara Schellhorn, supervisor of personal health. Parents are not required to have children immunized; Pennsylvania requires childhood vaccinations for school-age children, but parents can file for an exemption for moral, religious or philosophical reasons. Bucks hasn't seen any decline in immunizations; last year the department vaccinated more than 10,000 adults and children, Schellhorn said. This year all local schools reported their students were current with vaccines, she added. While Schellhorn understands parents' concerns, the anti-vaccine movement worries her as a public health advocate. “If you can prevent a disease, why wouldn't you?” AN OVERNIGHT CHANGE Debbie Gies put off vaccinating her then 13-month-old son Sam, after he was diagnosed with benign lymphedema, where excess fluid collects in tissue and causes swelling. But eventually she went against her gut reaction and took him for his routine diphtheria- tetanus-pertussis shot. That was in 1981, when vaccine safety was not something most people questioned. Hours later, Sam developed a fever, he started vomiting and screaming. The fever broke, but the next night it happened all over again. Soon after, Sam — who had been walking and started talking — avoided eye contact. He started crawling. He stopped talking. He became irritable. “I told my husband, it seems like he changed after that shot,” said Gies, a Bristol Township resident who is also attending the D.C. rally today. Sam, now 27, was later diagnosed with autism, and Gies refused to have him vaccinated again. Later, Gies had two more children, a daughter, who is now 25, and another son, Michael, 19. Neither was vaccinated. But Michael also has autism, though he is high functioning. Gies believes Sam would be more like Michael had she not vaccinated him. Gies insists she is not against vaccines, but she believes immunizations may aggravate underlying genetic disorders or compromised immune systems resulting in neurological damage. “I truly think the stronger ones are the ones who survive,” she said. DID YOU KNOW? Since 1990, the Vaccine Adverse Event Reporting System, a national database that collects reports of adverse post-vaccination events, has received more than 123,000 reports of bad reactions. In Bucks County, the number of school-age children with autism spectrum disorders more than tripled between 1999 and 2006, from 232 children to more than 700, according to state education statistics. Last year the Bucks County Health Department administered 480 mumps-measles-rubella vaccines, and the first four months of this year it administered 168. Jo Ciavaglia can be reached at 215 949-4181 June 4, 2008 6:54 AM ----------------------------------------------------------------------------- Scout leader's cancer struggle gives troop insight By Lori Gilbert Record Staff Writer June 05, 2008 6:00 AM When the members of Girl Scout Troop 2183 finish presenting the colors at Saturday's Relay for Life opening ceremonies at Weber Point Events Center, chances are good they won't leave once the flag is raised. Their appearance at the Stockton edition of the annual fundraising event for the American Cancer Society isn't a token moment of community service. It's personal. Their troop leader, Shiree Conklin, in addition to taking them on camp outs and helping them sell cookies, has introduced them to cancer. PREVIEW STOCKTON When: 9 a.m. Saturday through 9 a.m. Sunday Where: Weber Point Events Center Information: (800) 227-2345 LODI When: 10 a.m. Saturday through 10 a.m. Sunday Where: Lodi Grape Festival Grounds, 413 E. Lockeford St. Information: (800) 227-2345 Conklin and her best friend, Tina Robinson, started the troop three years ago. Conklin wanted to spend time with her daughter, Autumn, then 9, hoping to make up for time she'd missed during the previous two years as she was fighting cancer. When Kiana, one of her scouts, asked her why she had no breasts, Conklin, with the permission of Kiana's mom, told her. "I sat down with them in small groups, and explained I was really sick," Conklin said. "Having Autumn there was really good because she was able to put in little bits of stuff that made the girls understand a little more." Conklin didn't go into all the details of what it's like to be a 27-year-old single mother of two young children diagnosed with breast cancer. She couldn't completely convey the agony of a double mastectomy and the failure of reconstructive surgery that left her flat chested. Girls 5 to 13 can't grasp the magnitude of carrying the hereditary BRCA gene that attacks the female organs and led Conklin to also suffer cancer of the ovaries, cervix, uterus and liver. What she did teach her young scouts, though, is that while the median age of diagnosis for breast cancer was 61 years and only 1.9 percent of those diagnosed from 2001-05 were aged 20-34, according to the National Cancer Institute, it can happen to any woman. Conklin's own doctors didn't think it possible. When she felt a lump in her breast in 2003, her doctor dismissed it because of her age. Her gynecologist sent her for a mammogram, which technicians declined to conduct on a 27-year-old. A sonogram revealed more than a simple lump, and the mammogram was finally performed. "It was a pain trying to get them to actually take it serious," Conklin said. "The type of cancer I had was so aggressive that it would have killed me if I'd left it alone." She began a two-year ordeal of surgeries and chemotherapy that has left her with lymphedema, the swelling of her arms and legs that resulted from the removal of lymph nodes, nerve damage in her feet and fibromyalgia, which is chronic pain in her joints. She sometimes walks with crutches or a cane. Other times she uses a wheelchair. The toll is more than physical. "I lost practically all my friends," Conklin said. "I wasn't able to go to bars, to drink, to lay out by the pool. It's horrible in so many aspects. It's not just cancer. It's the drugs and, after the meds, the chronic pain from the different drugs they've pumped into your system. There's the headaches and the scars. There's so much residual. Even four, five years later, it's still lingering." All of that is what makes participating in Relay for Life vital to Conklin. "It's a time where you're accepted," Conklin said. "You don't have to pretend to be whole. You're not. You don't have to pretend to be something society expects you to be. You're around people who understand you, have been through what you've been through or are going through." This is the third Relay for Life in which Conklin will be part of the Pipe Dreamers team. The event features a survivors breakfast sponsored by the South Stockton Lions; live entertainment throughout, beginning with Seija Anderson singing the national anthem; and food and carnival game booths along with informational centers. Teams of people take turns walking the course during the 24-hour relay. This year's theme is "Celebrate, Remember and Fight Back," to honor the survivors, remember those who have been lost to the disease and to fight back during the other 364 days of the year. As in the past, she'll make her way around the Weber Point course on the first lap with fellow cancer survivors. "When you look around, you're in awe," Conklin said. "Everyone is there for, essentially, you. It means so much. Once you step on the track for the first lap with all the survivors and you're looking around, you're not alone. We have a strong community." The "community" has grown over the course of the relay, which is in its 11th year in Stockton. There are 63 teams, up from 47 last year, volunteer chairwoman Randie Chunn said. It's something Conklin anxiously awaits each year, and something she wanted to share with her Girl Scouts. "I guess it's selfish on my part," she said. "I wanted my girls to get involved in the relay because it means so much to me, and the girls mean so much to me. I wanted to combine the two. I really truly believe they're going to get a lot out of it in the long run." Contact Lori Gilbert at (209) 546-8284 ------------------------------------------------------------------------------ Cancer survivor's healing garden is ideal place to many By Dan Scanlan, My Mandarin Sun It's tucked a wning and decorated with flowers, plaques and big pink ribbons. Called a Healing Garden, it will be a private oasis of peace for breast cancer survivors shielded by a white fence and owned by a survivor herself. And at 2 p.m. Sunday, National Cancer Survivors Day, this quiet corner of flowers and wicker chairs was blessed by the Rev. Anthony Bonela, parochial vicar at St. Joseph's Catholic Church. The private garden is the brainchild of Cheryl Feeney, a cancer survivor herself over the past five years who also operates an online business that helps cancer survivors, plus has items on sale at local drug stores and gift shops. The idea was to give a breast cancer survivor some place closer to home to meet in support groups, most of which meet in the downtown area, she said. "There really isn't anything in Mandarin, so it is nice to have a respite, a quiet place where it is safe. This took a while to do, but I had a backyard with a lot of water and some floods, so it took a lot longer," she said. "It feels really great. It is something I thought about and was always on my mind, taking something from the beginning and giving birth to it." Bobbi de Cordova-Hanks, a three-time cancer survivor, breast cancer support group facilitator at the Women's Center of Jacksonville and founder of its Bosom Buddies program, said the new garden could become a very peaceful place for the people she works with daily. Survivors "have no place as beautiful." "That is wonderful to open her heart and her home to people on their cancer journey," she said. "Any place that can be serene and peaceful and a non-threatening environment can be a real plus for healing. Most of the time you are in a very sterile environment, seeing doctors in hospitals. Even support groups like ours meet in places of convenience that are not healing spaces." Feeney was diagnosed with breast cancer in 2000, when she was a tax accountant in Rhode Island. She underwent chemotherapy and radiation treatment. After therapy, she learned she could develop lymphedema, a painful swelling that typically affects the arms. It forced her to retire because carrying heavy audit cases could aggravate the condition. That's when she decided the plastic medical bracelet she got at the hospital wasn't too nice looking. She developed a collection of jewelry-designed medical bracelets, evolving into a collection of charms, brooch pins, lockets, pendants and gifts, designed to support individuals touched by breast cancer and other medical conditions. The idea for a garden-like gathering area arose when she moved to Jacksonville in late 2005. She continued selling her items online as well as at local boutiques and drug stores, with all after-tax profits going to the Healing Ribbons Fund at the Rhode Island Foundation. The philanthropic organization allows her to direct where she wants the money used in support of the fight against breast cancer and related diseases. But she also remembered how she wanted a quiet place to talk to someone when she learned of her diagnosis. "That is why I feel the way I do. When you hear that word [cancer] you wish you could call everyone. That is why my online group has been so good. But it is virtual," she said. "People are scared. They want to talk. Sometimes they don't want to be seen. But there are others who want to reach out and touch." The Healing Garden starts outside her townhome's white wooden fence, with a rock pathway leading to a garden arbor painted on the gate itself. Feeney asked local artists Sonya Cox, Louise Cruz and Leneke' to do the art work. Inside is a rocky path lined with flowering plants and pink paving stones, some with pink ribbons inlaid in them. The landscaping was done by Kathy Esfahan. Then around the corner lies a private corner with wicker chairs, surrounded by palm trees and flowers with a plaque that reads "If you dream, dream big ... it might come true." Feeney paid for all of it in stages. The final step was to have the gardens blessed, the artists and others who helped bring the garden alive joining her there Sunday, followed by a luncheon to celebrate it and National Cancer Survivors Day. As for use of the garden, Feeney said she will work with groups like Bosom Buddies and area hospitals to set up support group meetings. For more information on breast cancer survivor Cheryl Feeney's Healing Garden, call 288-6927. ---------------------------------------------------------------------- Another fight follows cancer Compression sleeves help lymphedema patients. By T.J. GREANEY of the Tribune’s staff Published Saturday, June 7, 2008 On Thursday, Joyce Wall proudly raised her swollen left arm and pointed to a bump. "See an elbow there? I feel a bump," she said with a smile. "We knew it was in there somewhere," said Vickie Parker, Wall’s occupational therapist. Though the ritual seems strange to an outsider, it’s business as usual for people in the Lymphedema Therapy Program on the second floor of Ellis Fischel Cancer Center. Wall, a resident of the Miller County town of Brumley, was driven this week by her husband to the cancer center because - after twice defeating breast cancer - lymphedema recently reappeared in her body, causing her arm to swell. A side effect of cancer treatment, lymphedema occurs in patients who have had lymph nodes removed in surgery or damaged by radiation therapy. The altered lymphatic system tends to retain fluid in certain spots, causing swelling. The condition can be particularly dangerous because the fluid is rich in a protein that feeds bacteria. An infection of the area - known as cellulitis - can travel through the bloodstream and can be fatal. So, for Wall, even the slightest decrease in swelling is cause for celebration. "Right now, after a couple of days of therapy, it is movable," Wall said, reaching to scratch her back with the arm that is twice its normal size. "Before I came in, it was so swollen, so big, so big, so big, that to reach here and scratch would have been impossible," she said. The Lymphedema Therapy Program also has reason to cheer. They recently received a $4,500 grant from not-for-profit Susan G. Komen For The Cure to help pay for supplies necessary to treat lymphedema. The grant fills a gap in coverage left by many insurers. Karen Wingert, a physical therapist at Ellis Fischel who also is an associate professor at the University of Missouri School of Health Professions, said the money is badly needed to pay for supplies for what is a lifelong condition. "What we tell people is that we can control it but we can’t cure it," Wingert said. "And that’s devastating to women who thought they just fought the battle of their life with cancer and won. It’s a constant reminder." Lymphedema is treated first with daily massage therapy and bandages wrapped tightly around the affected area. After several weeks of therapy, the swelling should decrease, but the patient must contain it by wearing a special elastic sleeve. The sleeves cost $200 to $500 each and must be replaced at least every six months for the rest of the patient’s life. Many insurers - including Medicaid and Medicare - won’t pay for the sleeves, and many patients can’t afford them. In past years, local advocates resorted to holding garage sales to pay for the sleeves. Still, some women went without a regular change of therapeutic sleeves. "Getting a grant is way better than having a garage sale," said Wingert. The stakes are high. Women like Wall who can’t afford the sleeves are in danger of having lymphedema return when the elastic on the medical sleeve wears out. "You have to go through very, very red tape in order to get any help paying for that stuff," said Wall, whose lymphedema came back after she went three years without replacing her sleeve. Advocates are happy about the grant but say it only covers a fraction of the need. They wish a lack of federal funding didn’t make it necessary. "There is a problem there," said Julie Peterson, a research nurse and facilitator for a local support group, the Mid-Missouri Lymphedema Network. Leading Surgeons at St. Mary's Medical Center Set New Standards for Surgical Procedures with Novadaq SPY(R) System SAN FRANCISCO - (Business Wire) St. Mary’s Medical Center (SMMC) is one of the first hospitals on the West Coast to routinely use the SPY® Intra-operative Imaging System (SPY or SPY System) in cardiothoracic procedures and plastic reconstructive surgeries. The SPY System is the only FDA- approved, intra-operative imaging system that provides real-time fluorescent images while the patient is in the operating room. SPY images enable surgeons to optimize surgeries, eliminate guesswork and potentially avoid post-operative complications including repeat surgical operations. The SPY System enables cardiac surgeons at St. Mary’s to simply and efficiently confirm proper placement of bypass grafts and visually assess their effectiveness during coronary artery bypass graft procedures. Similarly, physicians at SMMC’s Plastic Reconstructive Orthopedic Surgery Center performing reconstructive procedures use the SPY System to see the blood flow in co-joined vessels, micro-vasculature and related tissue perfusion in real-time. “We’re committed to adopting technology that allows us to provide the highest quality of cardiac care possible to our patients at St. Mary’s,” said Dr. Eddie Tang, cardiac surgeon at SMMC. “The SPY System enables us to immediately visually assess the blood flow in our bypass grafts, confirm that we have performed the best possible bypass procedure, and potentially improve immediate and long-term outcomes for the patient.” The SPY System combines the use of an infrared laser, high-speed imaging and a fluorescent imaging agent. The imaging agent, which is administered to patients intravenously during the procedure, emits light when stimulated by the infrared laser. During surgery, the imaging agent lights up in blood flowing through the circulatory system while the camera captures the live images. If the images indicate that a graft might not be functioning optimally, the surgeon can immediately make revisions in the operating room. Traditionally, surgeons have been forced to make an educated guess about whether bypass grafts, co- joined arteries or veins are functioning properly. Cardiac surgeons have only been able to get images of the heart and vessels after the patient’s chest is closed and the patient has been removed from the operating room. Likewise, surgeons performing plastic reconstructive procedures have not been able to easily perform real-time imaging in the operating room. Use of the SPY System may reduce the number of patients that must return to the operating room for the revision of improperly functioning or potentially misplaced grafts. According to Dr. Charles Lee, director of microsurgery at St. Mary’s Medical Center, “The SPY technology allows plastic surgeons to determine the blood supply to tissues we transplant to reconstruct the human body. Specifically, in breast reconstruction and lymphedema surgery, we use specific tissue types from the abdomen, buttocks or thighs, and with the SPY we can determine which parts of these tissues are best to use.” SMMC now joins other prestigious institutions utilizing the SPY System, including the Cleveland Clinic Foundation, Stanford University Medical Center and the Arizona Heart Institute. About St. Mary’s Medical Center Founded 150 years ago, St. Mary’s Medical Center is one of the first hospitals in San Francisco. It’s the home of several medical firsts including the nation’s first digital cardiac catheterization laboratory, the first balloon angioplasty for coronary artery disease and the first total hip replacement surgery. St. Mary's continues to adopt the latest advances in medical technology and practices with specialized centers for plastic reconstructive orthopedic surgery, and innovative cardiovascular, bariatric, oncologic and acute rehabilitation services. With more than 575 physicians and 1,100 employees, St. Mary's full-service acute care facility is committed to its mission to deliver compassionate, high quality, affordable health services to the communities it serves. St. Mary’s pioneering spirit endures and it is well poised to continue its tradition of providing health and healing for the San Francisco community. For more information, please call (415) 668-1000 Mortar Jamie Fishler, 415-772-9907 ext. 117 (Media) ------------------------------------------------------------------------------ SAN DIEGO, June 12 CA-BioimpendanceGuide SAN DIEGO, June 12 /PRNewswire/ -- Recent guidelines published by the Clinical Resource Efficiency Support Team (CREST) provide further support for the use of bioimpedance technology for the early assessment of lymphedema. The published guidelines for Northern Ireland titled "Guidelines for the Diagnosis, Assessment and Management of Lymphoedema" are the result of an expert panel including patients and healthcare professionals that reviewed the evidence for diagnosing, assessing and treating lymphedema. The guidelines support the need for a shift in treatment focus from a reactive approach to one focused on the early assessment and early intervention of the condition. Bioimpedance technology featuring high sensitivity and specificity support this approach. This surveillance method of diagnosis and treatment reflects recommendations recently published online in the journal Cancer, the official journal of the American Cancer Society. To view the published guidelines online, please visit http://www.crestni.org.uk/crest_guidelines_on_the_diagnosis__assessment_and_ma nagement_of_lymphoedema.pdf. (Due to the length of the link, please copy and paste into your browser.) About Lymphedema Lymphedema is a condition that can cause significant swelling of the upper and lower extremities due to the build-up of excess lymph fluid. This can occur when the lymphatic system, which is responsible for draining excess fluid from the body and is a key component of the immune system, is damaged or altered. In breast cancer patients, this can occur after surgery, such as removal or biopsy of the lymph nodes, and/or radiation therapy. It is estimated that 6 percent to 40 percent of patients with breast cancer develop lymphedema, and that it often occurs within the first two years after surgery. For some cancer survivors and others at risk, a low level lymphedema can occur 10 years to 15 years following the initial primary treatment and develop into a condition that has a serious impact on overall health and quality of life. For more information about lymphedema, visit http://www.nci.nih.gov/cancerinfo/pdq/supportivecare/lymphedema/patient/. About ImpediMed ImpediMed is the world leader in the development and distribution of medical devices employing Bioimpedence Spectroscopy (BIS) technologies for use in non-invasive screening and monitoring of human disorders and diseases. ImpediMed's primary product range consists of a number of medical devices that enable surgeons, oncologists and radiation oncologists to detect early onset secondary lymphedema in breast cancer survivors, before the onset of symptoms that are detectable using the most commonly used clinical technique, and before the condition becomes a matter of lifelong management and impairs the quality of life of the cancer survivor. ImpediMed has the only medical BIS device with FDA clearance in the United States for the clinical assessment by health care providers of secondary lymphedema of the arm. Contacts: Wendy Lau or David Schull Russo Partners LLC (212) 845-4272 SOURCE ImpediMed -------------------------------------------------------------------------------------- Fight cancer risk with exercise Study: physical activity helps reduce risk of cancer recurrence By Lindy Washburn MCT Published on: 06/12/08 HACKENSACK, N.J. — The standard weapons in the fight against cancer — surgery, chemotherapy and radiation — may soon be joined by something far simpler: exercise. New research shows that regular physical activity helps reduce the risk of recurrence of breast cancer and slows the advance of prostate cancer. In a few years, exercise will probably be prescribed regularly for cancer rehabilitation, said Melinda Irwin, an expert on cancer and exercise at Yale University School of Medicine. Personal trainers may join oncologists, surgeons and radiologists as members of the cancer-treatment team. Exercise will become a "targeted therapy, similar to chemotherapy or hormonal therapy," Irwin said Any regular physical activity — the equivalent of a 30-minute walk, five times a week — will do. "Don't think you have to work up a sweat or train for a marathon to benefit," Irwin said. Exercise offers many other advantages: It fights the fatigue caused by cancer treatment, calms anxiety and helps survivors feel better about themselves and their bodies. Some personal trainers now specialize in working with cancer patients and more will soon be certified through a program of the American College of Sports Medicine. The Ridgewood YMCA offers a 12- week strength-training and fitness program for cancer patients and survivors. There are 10 million cancer survivors in the United States, 22 percent of them women who have had breast cancer, 17 percent of them men who've had prostate cancer. Exercise makes sense for most of them — to live longer, avoid other health problems, and just feel better Heart attack patients are now routinely put on exercise plans. But workouts for cancer patients are neither prescribed by doctors nor covered by health insurance. "We're where cardiac rehab was 20 years ago," Irwin said. Once exercise was shown through research to prevent fatal heart attacks, 12 weeks of rehabilitation became the standard of care for most heart patients. In fact, many hospitals opened cardiac rehab centers. One day, that will probably happen with cancer patients. In the meantime, as a cancer survivor, I can't see a downside to starting now. It needn't cost anything — walking is free and you can work out at home. The hardest part is getting started and making time. But what stronger motivation can there be than avoiding another go-round with cancer? Besides, I feel so much better when I exercise. Lately, during a high-anxiety round of follow-up tests, my early-morning swim and gym sessions have kept me grounded. Even when I'm bruised from biopsies, a walk always restores me — especially when I have the company of my husband or a friend. Even with a low level of exercise, people benefit psychologically, said Rita Musanti, an oncology nurse- practitioner at the Cancer Institute of New Jersey who earned her doctorate studying exercise and cancer recovery. With so many cancer survivors in the community, she'd like to see informal networks created to encourage recovering cancer patients. I certainly cherished the encouragement from swimmers or gym members I'd known only by face who quietly introduced themselves and revealed their own stories of cancer recovery. There are a lot of us out there. We draw inspiration from each other. 'Out of that slump' Beth Wajts of Hillsdale joined the Ridgewood YMCA's free "Living Healthy, Living Strong" class in January after her second surgery for breast cancer, followed by chemotherapy and radiation. "I cannot believe the way I walked in, and the way I walked out," she said. "I never believed I would get out of that slump," Wajts said. "Now I feel incredible." One of her classmates, Joyce Murray of Hawthorne, had three surgeries in an eight-week period last summer, then chemotherapy with many complications. No amount of sleep could cure her fatigue, she said. After she started the twice-weekly program of resistance training and cardiac fitness, "I was surprised at the quick rebound," she said. "I really feel better." Recovering from cancer was her "job for the last year," she said, but at the program's conclusion, she was looking forward to getting back to work as a school nurse. Angelo Chiusano, 81, joined after 43 radiation treatments for prostate cancer and surgery for an aortic aneurysm. Thanks to the camaraderie in the weight room, "I've gained a new family," the Oakland resident said. "It's made such a difference in my feelings." After doing the weight-resistance circuit in the gym each session, he swam. "Then, when I go home, I walk a mile," he said. He's continued his workouts even though the program has ended. Researchers are working to understand how physical activity helps fight cancer. Their findings so far suggest that exercise: • Reduces blood levels of insulin, a substance in the body that causes cells to divide and grow more quickly. Women with high levels of insulin have a slightly higher risk of breast cancer and a much higher rate of recurrence and death. • Helps repair infection-fighting T-cells, restoring the immune system after it has been damaged by chemotherapy. • Reduces levels of circulating estrogen and testosterone, two hormones linked with breast, endometrial and prostate cancers. Even with medication to suppress estrogen production, some estrogen is stored in fat cells. Exercise may help by converting fat to muscle. • Prevents weight gain and promotes weight loss, important because obesity is associated with lower rates of survival for many forms of cancer. For women with breast cancer, obesity at the time of diagnosis, and weight gain afterwards, are associated with worse outcomes. The heavier and less active a person is, the more likely her cancer will return. Most of the scientific work so far has focused on women with breast cancer, simply because there are so many of us. But studies have also shown exercise has positive effects for survivors of colorectal and prostate cancers. Among men older than 65, three hours of vigorous activity a week was associated with a decline in death from prostate cancer. Exercise is now considered so beneficial that cancer experts are even encouraging patients to begin or resume exercise while treatment is under way. Workouts might need to be scaled back in intensity and pace, but "evidence strongly suggests that exercise is not only safe and feasible during cancer treatment, but that it can also improve physical functioning and some aspects of quality of life," according to the American Cancer Society. Lockey Maissoneuve, a 41-year-old personal trainer, went through two mastectomies and chemotherapy two years ago. She is now is training for a triathlon. "If you're in treatment, the first week or two you try to do anything, you need to take a nap," she said. "If there's a day you want to exercise, do it." Wearing a wig was uncomfortably hot in the gym, so she switched to a kerchief. With her immunity reduced by chemo, she wiped down the equipment before she used it. She is now certified to work with cancer patients. "The trainer is almost like your bodyguard," said Julie Percy, of Parisi Sports Club in Midland Park, who also specializes in work with cancer patients. "We maneuver you to the right equipment, give you a sense of security." When scar tissue forms after surgery, it limits flexibility. Percy helps women who've had mastectomies and underarm incisions restore the range of motion. Trainers have to be particularly attentive when someone has had surgery to remove lymph nodes. If the tiny valves in the vessels that transport lymph around the body fail, that can lead to lymphedema, a dreaded side effect of cancer surgery. The arm, for breast patients, or the leg, for prostate patients, becomes permanently swollen. "We watch the amount of weights they use," Percy said. She starts light and increases gradually. Women who have lymphedema, or a heightened risk of it, wear a compression sleeve. Extra energy Rita Scoccola, 43, of Wyckoff resumed exercising a year after she had a double mastectomy in 2000. She works out weekly with Percy and is in the best shape of her life. "There's always an awareness" of the ways her body has changed as a result of the surgery and reconstruction, Scoccola said, but her workouts, combined with healthful eating, have given her lots of energy. The path back from a cancer diagnosis varies for each person: We start at different levels of fitness, and go through treatments of varying severity. Feeling comfortable in my own body again, after the invasion of a terrible disease and then the medical procedures, restored much of my sense of health. It also helped me feel I could help myself, at least a little. Becoming active again, said Maissoneuve, helped her "realize that cancer is not a jail sentence. It's a big bump in the road. But you can find your new normal, and have a great life." ---------------------------------------------------------------------------- Tactile Systems Technology Announces Medical Advisory Board MINNEAPOLIS--(BUSINESS WIRE)--Tactile Systems Technology, which develops, manufactures and markets products to treat vascular disorders such as lymphedema, announced the formation of its first Medical Advisory Board. Initial members are Stanley Rockson, M.D., Professor of Lymphatic Research and Medicine, Stanford University School of Medicine; Harvey Mayrovitz, Professor of Physiology, College of Medical Sciences, Nova Southeastern University; and chair Kathleen Francis, M. D., Medical Director, St. Barnabas Lymphedema Treatment Center. “This board represents a cross section of well respected authorities on lymphedema,” said Gerald R. Mattys, Chief Executive Officer, Tactile Systems Technology. “We believe they will be instrumental in guiding our company as we increase the size of our direct sales force, fund larger clinical trials and expand into new clinical indications, such as the treatment of chronic wounds. In essence, they will help us gain consensus on how our Flexitouch system fits into the standard of care treatment continuum for lymphedema and venous disorders.” In 2008, Tactile Systems Technology raised $11.8 million to pursue opportunities for its Flexitouch system, which delivers therapy that simulates manual lymphatic drainage (MLD) through garments covering an individual’s limb and trunk. Preparing the trunk for lymphatic drainage is a unique feature of the Flexitouch system, which follows the principles of MLD as provided by therapists in clinical settings. Topics of conversation at the first board meeting, held May 15, included payer coverage criteria and clinical research initiatives. The board decided to move forward with two new clinical studies – one comparing pumps on the market today and a second to measure changes in edema of the trunk during therapy. In 2004, Rockson led a clinical trial that showed the Flexitouch may provide better maintenance edema control than self-administered massage in breast cancer-associated lymphedema. In 2007, Mayrovitz led a clinical study that compared pressures delivered by a competitive sequential compression device with those delivered by the Flexitouch. Francis, a practicing lymphedema physician and member of the National Lymphedema Network’s medical board, has counseled Tactile Systems Technology since early 2005. Lymphedema is the abnormal accumulation of lymph fluid in body tissues, typically in the dermis of the arms or legs due to blockage or inadequacy of lymph circulation. It is often the unintended consequence of cancer treatment. Approximately 25 percent of breast cancer survivors develop lymphedema within two years of treatment. In 2007, Tactile Systems Technology was named “Corporation of the Year” by the Lymphatic Research Foundation. For copies of the clinical studies, contact Mary Rausch at mrausch@tactilesystems.com. --------------------------------------------------------------------------------------------- J Am Acad Dermatol. 2008 Aug;59(2):324-31. May 29. Lower extremity lymphedema update: pathophysiology, diagnosis, and treatment guidelines. Kerchner K, Fleischer A, Yosipovitch G. Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157, USA. Lower extremity lymphedema is an important medical issue which causes morbidity and is frequently seen by dermatologists. The subject has not been adequately addressed in dermatologic literature for many years. Primary lymphedema is caused by an inherent malfunction of the lymph-carrying channel, in which no direct outside cause can be found. Secondary lymphedema is caused by an outside force, such as tumors, scar tissue after radiation, or removal of lymph nodes, which results in dysfunction of the lymph-carrying channels. Treatment is based on rerouting the lymph fluid through remaining functional lymph vessels. This is accomplished through elevation, exercises, compression garments/devices, manual lymph drainage, and treatment is combined with good skin care practices. --------------------------------------------------------------------------------- 6/12/2008 Two-time breast cancer survivor among Senior Championships participantsBy Lucas Wiseman and Wendy Clem USBC Communications Linda McAndrews can't wait to get to the 2008 United States Bowling Congress Senior Championships next week in Reno, Nev., and try out her new 14-pound fingertip ball. The Farmington, N.M., bowler has no intention of backing down from the challenge of a heavier ball, even if it means changing her entire delivery. It's the same attitude she used to beat breast cancer not once but twice. "After my surgeries in 1992 and 1998, I told the doctors I was not going to quit bowling so don't even think about it," said McAndrews, a 60-year-old retired business teacher. "I also said that if I couldn't use my right arm anymore, I would switch to my left and start all over again, if that's what it took." McAndrews will put her new ball to the test as one of more than 400 senior bowlers from across the country who will compete at the National Bowling Stadium in the USBC Senior Championships starting Tuesday. Now carrying a 164 average, McAndrews hopes to regain her pre-cancer average of 173 and received some tips at a recent clinic. The coaches convinced her to move up from a 13-pound ball to 14 pounds. Her switch in 1999 to a fingertip already gave her renewed strength and control following a bout with Lymphedema, a painful after-effect of cancer and radiation therapy. "Not only has the drive to get well made me stronger and a better person overall, it has also made me an improved and more determined bowler," she said. "I've developed such stamina that I've rolled as many as 21 games in a row." McAndrews, who bowls with other cancer survivors as well as several former students in her league, said the geographic area around Farmington, N.M., is fraught with cancer stories, primarily due to the uranium mining industry there. The prevalence of the disease led to the establishment of San Juan Regional Medical Cancer Center, a teaching hospital. It's also home to an active chapter of the American Cancer Society, where McAndrews spends time as a volunteer. Before her 1995 retirement, McAndrews even incorporated her cancer progress and medical stories into classroom lessons. Students had curiosity and concern, both of which fueled her determination, she said. "The American Cancer Society's Reach to Recovery program provides important help for cancer patients," McAndrews said. "Bowl for the Cure is another way to raise awareness, and so is moving forward with my life with energy and hope." The USBC Senior Championships will feature a Women's and Open division, with bowlers competing in five age classifications (Super Seniors: 75 and older, Class A: 70-74, Class B: 65-69, Class C: 60-64 and Class D: 55-59). In order to qualify for this national event, competitors must have won their state association's senior handicap all-events title. The field is made up of bowlers from 49 states (only Rhode Island is not represented) and Canada who will compete for their share of more than $40,000 in prize money. The history of the Senior Championships, which is presented by the Eldorado Hotel Casino, dates back to the early 1960s, and from 1982 until 2002, the event was held on the championships lanes at either the Open Championships or the USBC Women's Championships. In 2003, the Senior Championships found a permanent home in Reno and has been held at the Stadium each year since. __________________________________________________________________ Jun 16 2008 Tactile Systems Technology Completes Accreditation with ACHC MINNEAPOLIS - (Business Wire) Tactile Systems Technology (www.tactilesystems.com) has been awarded accreditation status by the Accreditation Commission for Health Care, Inc. (ACHC). Tactile Systems Technology provides a patented, innovative, at-home therapy through its Flexitouch® System to improve the health and quality of life for individuals with lymphedema. Lymphedema is a chronic, progressive medical condition affecting more than two million people in the United States. It is caused by a disruption to, or malformation of, the lymphatic system resulting in the accumulation of excessive amounts of fluid, most commonly in the arms, legs and torso. It is often an unintended consequence of cancer treatment. Accreditation is a voluntary activity in which health care organizations submit to peer review of their internal policies, processes and patient care delivery against national standards. By attaining accreditation, Tactile Systems Technology has demonstrated its commitment to maintaining a higher level of competency and is striving for excellence in its products, services and customer satisfaction. “This accreditation is a fitting acknowledgement of the life-changing therapy delivered by the Flexitouch system,” said Gerald R. Mattys, Chief Executive Officer, Tactile Systems Technology, “and it validates the hard work that has gone into the development of our products and services.” ACHC, a private, not- for-profit corporation which is certified to ISO 9001:2000 standards, was developed by home care and community-based providers to help companies improve business operations and quality of patient care. Referring to the value of accreditation, ACHC President Tom Cesar said, “The survey process leads an organization to examine its policies and practices continually to clarify its strengths and improve its weaknesses.” Tactile Systems Technology, Inc. was founded in 1995 to develop and market a medical device for the effective treatment of lymphedema and venous insufficiencies. It received U.S. Food and Drug Administration (FDA) marketing clearance for the device in 2002. The Flexitouch system has been proven effective in relieving the symptoms of lymphedema and has recently received marketing clearance from the FDA for the treatment of wounds. In 2007, Tactile Systems Technology was named “Corporation of the Year” by the Lymphatic Research Foundation. Tactile Systems Technology Mary Rausch, 952-224-4885 Director of Marketing __________________________________________________________________ 06/29/08 Names & Faces CROPSEY — Kristin Helmers of Cropsey completed the doctor of physical therapy (DPT) degree May 23 from Midwestern University, Downers Grove. Helmers is the daughter of Dennis and Cindy Helmers of Cropsey. She graduated from Prairie Central High School in Fairbury in 2001. She has accepted a position with Evergreen Hospital in Seattle, Wash., where she will specialize in acute care and lymphedema. _____________________________________________________________________ June 30, 2008 Longaberger Horizon of Hope to Raise Money for American Cancer Society Breast Cancer Initiatives Horizon of Hope Products Available at 20 Percent Off for Limited Time NEWARK, Ohio--(BUSINESS WIRE)--The Longaberger Company is kicking off its 2008 Horizon of Hope campaign with a special offer that will enable customers to buy Horizon of Hope products at a 20 percent discount while also supporting American Cancer Society breast cancer research and education initiatives. The campaign features a Horizon of Hope Basket and other products that Longaberger designs exclusively for the fundraising effort. Proceeds ($2 from each Horizon of Hope Basket, accessory set or set of travel mugs) go to the American Cancer Society. The campaign is from July 1 through August 31, with the discount on Horizon of Hope products available from July 1 through July 16. “It is our hope that we not only spur more awareness of this program that is bringing results in the fight against breast cancer, but that this promotional offer also acts as a catalyst to raise more money for the American Cancer Society,” said Julie Moorehead, Longaberger’s national executive director of sales. Longaberger products can be purchased through independent Home Consultants nationwide or at www. longaberger.com. Since Horizon of Hope’s inception in 1995, Longaberger, its Home Consultants and the American Cancer Society have raised approximately $13 million and reached an estimated 19 million women with potentially life-saving information. “Our company and our Home Consultants are passionate about Horizon of Hope because we’ve seen first-hand how we are together making a difference,” Moorehead said. “We’re proud to support the American Cancer Society.” Horizon of Hope supports American Cancer Society programs aimed at improving the quality of and access to mammography services, breast imaging quality standards, the quality of clinical breast examinations, and the quality of life for young survivors and women with breast cancer recurrence. It also supports research into lymphedema, a debilitating swelling of the arms that can be a side effect of breast cancer treatment. To learn more, visit www.HorizonOfHope.com. Founded in 1973, The Longaberger Company is America’ s premier maker of handcrafted baskets and offers a variety of home and lifestyle products, including pottery, wrought iron and fabric accessories. There are approximately 45,000 independent Home Consultants in all U.S. states who sell Longaberger products directly to customers. ------------------------------------------------------------------------ July 1, 2008 Managing upper extremity lymphedema Denise Goodwin The Union-Recorder Few ordeals are as frightening as breast cancer treatment. The words chemotherapy and radiation alone produce anxiety and fear. When treatment is over, survivors are just so happy to be cancer-free that they often don’t consider the after-effects of their treatment — one of which is upper extremity lymphedema. Symptoms of this condition include limb swelling, tenderness, heaviness, tightness and pain in the arms, chest wall and soft breast tissue. Left untreated, lymphedema can lead to serious infections. Removing lymph nodes is an important part of breast cancer treatments so doctors can determine whether the cancer has spread from its primary site. Without these nodes, however, lymphatic fluid often builds up in tissues, causing lymphedema. Three stages — ranging from mild to severe — characterize lymphedema: n Stage One (mild lymphedema). During this phase, tissue is still in a pitting stage. This means that when you press an area with your finger, it will indent and hold the indentation briefly. Usually when you wake in the morning, the area is normal. As the day progresses, however, slight swelling can occur. n Stage Two (moderate lymphedema). The tissue now has a spongy consistency and is nonpitting. This means that when pressed, it bounces back without any indentation. Fibrosis (formation of fibrous tissue) begins in this stage, marking the beginning of limb hardening and notable swelling. n Stage Three (severe lymphedema). In this stage, swelling is irreversible, and usually the affected area is very large. The tissue is hard (fibrotic) and unresponsive. Treatment Options No quick cures for the condition exist. But you can find relief from properly trained therapists who can move accumulated fluid out of affected areas. This process is called Complete Decongestive Therapy (CDT). CDT is based on a self-education concept that includes Manual Lymph Drainage. This is a form of massage consisting of rhythmic strokes that stimulate lymphatic vessels to contract and encourage lymph flow. CDT also includes compression bandaging; exercise, such as swimming, biking and walking; and skin care. If skin isn’t maintained, lesions can develop that allow bacteria to enter an already immune- compromised system. This can lead to additional lymph system destruction, hospitalization or further functional limitations. With CDT treatment, however, skin is maintained and swelling reduction usually occurs in four to 14 treatments over two to four weeks, depending on the severity of your symptoms. To help sustain swelling reduction in the arms, medical-grade compression garments are usually required. If you have chest wall or breast lymphedema, compression bras are also available, offering support that conventional and athletic bras don’t. With proper education and care, lymphedema can be avoided: 1. Don’t ignore any slight increase of swelling in your arm, hand, fingers or chest wall. 2. Never allow an injection or blood drawing in your affected arm(s). 3. Have your blood pressure checked regularly. 4. Keep the edemic or at-risk (arm)s spotlessly clean. Use lotion after bathing, and when drying, be gentle and thorough. 5. Avoid vigorous, repetitive movements, such as scrubbing, pushing and pulling. 6. Avoid heavy lifting. Never carry heavy handbags or bags with over-the-shoulder straps on your affected side. 7. Don’t wear tight jewelry or elastic bands around affected fingers or arm(s). 8. Avoid extreme temperature changes when bathing or washing dishes. Protect your arm from the sun at all times as well. 9. Avoid trauma, such as bruises, cuts or sunburns. 10. When air traveling, wear a well-fitted compression sleeve. 11. Maintain your ideal weight through a low sodium, high-fiber diet, and avoid smoking and alcohol. With proper education, you can recognize lymphdema’s signs and seek treatment early to avoid the condition’s irreversible effects. Adapted from Advance for Physical Therapists _________________________________________________________________ July 30, 2008 Since then, studies have shown that exercise combined with diet can help prevent cancer recurrence, in addition to providing other benefits such as improved spirits and better overall health. Dragon boating has the added advantage of allowing members to vary the intensity of their workouts. “I come home from this and I feel great,” said Nichole Melone, 41. “Even with all the working out I do, this uses a different muscle.” Huifeng Reports Progress on Diosmin Contract Huifeng Bio-Pharmaceutical Technology (OTCBB: HFGB) announced it is on track to gain COS (European Certificate of Suitability) approval in September to provide Diosmin to Safic-Alcan, a French chemical company. Diosmin is a semisynthetic phlebotropic drug, a member of the flavonoid family that can be isolated from various plant sources or derived from the flavonoid hesperidin. It is used as a supplement to treat chronic venous insufficiency, hemorrhoids, lymphedema, and varicose veins. In November 2007, Huifeng signed an agreement with Safic-Alcan under which it will supply at least 50 tons of Diosmin to Safic-Alcan, an amount that increases yearly to 500 tons in the last year of the five- year contract. The COS is required before Huifeng can begin delivering product. Huifeng expects to begin delivery Diosmin in the fall, and it has begun building up its inventory of the product in anticipation of those deliveries. http://www.istockanalyst.com/article/viewarticle+articleid_2455295~title_Huifeng-Reports-Progress.html _______________________________________________________________________________ _ July 26, 2008 Dragon boat crew's special Cancer survivors come together for workouts By Julie Brossy UNION-TRIBUNE MISSION BAY – In their battles with cancer, they've been through surgeries, radiation, chemotherapy and more. Some are still under treatment, and they live with the possibility that the disease could recur. But you would never guess that from the energy and enthusiasm that the women of Team Survivor bring to their weekly dragon boat workout on Mission Bay. At the command of “paddle, set, go,” crew members plunged paddles into the bay on a recent Sunday. As they pulled back, the heavy dragon boat leapt forward and sliced through the flat, gray water. “More than anything, it's about the camaraderie,” said Penny Navarro of La Mesa. “This puts you with people who have been in the same place you have been, and it's easy to work together when you have that commonality.” Navarro, 53, was one of 17 team members who gathered to paddle the traditional Chinese boat at the Youth Aquatic Center on Fiesta Island. Cancer-free after treatment for an early- stage breast cancer in 2001, she learned of the dragon boat team through a woman in her quilting class, and has been to four practices. “It's a 10-mile drive, but at this point in my life, I'm looking to make that connection,” said Navarro, an executive assistant in the University of San Diego's continuing education program. The dragon boat crew, which began forming in April, is one of scores of cancer survivor boat teams in the United States, Canada and several other countries. While most teams are composed of breast cancer survivors, some, such as San Diego's, also include people who have had other types of cancer. The San Diego team is hoping to recruit new members. The dragon boat movement for cancer survivors came about after a Canadian doctor, Donald McKenzie, formed a breast cancer team in 1996 on the theory that paddling would help women strengthen their upper bodies, improve their range of motion and stimulate the immune system, among other benefits. At the time, it was common for doctors to order restrictions on breast cancer patients' activity in the belief that exercise might bring on lymphedema, a type of swelling that can be a side effect of radiation and lymph node removal in breast cancer treatments. No new cases of lymphedema occurred among those first team members. Since then, studies have shown that exercise combined with diet can help prevent cancer recurrence, in addition to providing other benefits such as improved spirits and better overall health. Dragon boating has the added advantage of allowing members to vary the intensity of their workouts. “I come home from this and I feel great,” said Nichole Melone, 41. “Even with all the working out I do, this uses a different muscle.” DETAILS Dragon Boats What: Team Survivor dragon boat crew. Who is eligible: Women with a history of cancer. A medical release and consent form are required. All levels of fitness are welcome. Where: Youth Aquatic Center, Fiesta Island, Mission Bay. When: Practices are held most Sundays from 8:30 to 10 a.m. Contact: Cheance Adair, adair@sandiego.edu, or Angie Bagnas, (858) 578-5731. _____________________________________________________________ July 2, 2008 Rockstock lineup still growing Still more bands are being added to the Aug. 16 Rockstock lineup. Organizer Lachlan Kennedy announced Monday that Flatlined, Finding Core, Kid Gib, Square Root of Margaret, Bury the Bully and Mean Tangerine are now on the bill. Finger Eleven, Sloan, the Trews and Thornley are already booked for the show, to be held at the Chatham-Kent Municipal Airport. For more details and ticket information, visit www.rockstockconcert.com. New address for Cultural Coalition The Chatham-Kent Cultural Coalition has moved to the United Way Community Resource Centre on McNaughton Avenue. The cultural integration organization assists community partners in the attraction and retention of newcomer business owners, provides support to immigrant entrepreneurs and assists with the integration of all cultural and newcomer groups in Chatham- Kent. The United Way office is home to several community groups and the resource centre provides meeting rooms for not-for- profit organizations. For further information on the relocation of the Chatham-Kent Cultural Coalition, contact Teresa Fysh or Karen Kirkwood-Whyte of the United Way at 519-354-0430. The United Way office is located at 425 McNaughton Ave. in Chatham.Fundraiser goes beyond its goal A fundraiser for a local infant has exceeded all expectations. "A Night of Music & Dance for Peyton" raised $12,000 for Shawn and Deb Meriano and their daughter. It was held last Thursday at the Ursuline College Chatham theatre. Deb was diagnosed with cancer during pregnancy. Peyton was born 13-weeks premature and spent four months in the neonatal intensive care unit in London, while her mom underwent chemotherapy and radiation treatments. In a release, organizer Charlene Roy said she was hoping for $5,000. She praised the performers and volunteers for making the night a success. Lymphedema session coming An information session about lymphedema will be held at Myles' Miracle Mission CANcer Assist Wellness Centre on Saturday. Lymphedema is abnormal swelling that can occur as a result of mastectomies and lumpectomies. Registered massage therapist and certified manual lymph drainage therapist, Freda Yako-Malott, will be facilitating the session. The program, which is free for cancer patients and their families, will be held from 10 a. m. to noon at the centre on Victoria Avenue. To reserve a space, call 519-351- 4811. No fish licence for weekend events Residents can fish licence-free in provincial waters during the Ontario Family Fishing Weekend. From this Friday until Sunday, there will also be more than 50 fishing events, derbies and festivals across the province. During family fishing weekend, anglers fishing without a licence must follow the conservation licence limits set out in the Ontario Recreational Fishing Regulations Summary. Information on these limits will also be available onsite at most local events. For more information, visit www.familyfishingweekend.comor call the Natural Resources Information Centre at 1-800-667-1940. Voyeurism suspect to return to court A 48-year-old man accused of voyeurism is scheduled to return to court on Aug. 7. Defence lawyer Greg Elliott appeared on behalf of Charles David Huls, of Charing Cross Road. A pre-trial for Huls was held on Monday at Chatham court and Elliott requested an adjournment to the August date for a continuation of the pre-trial. Huls is facing three charges of voyeurism in connection with a June 1, 2007 incident. Police describe voyeurism as a person secretly filming someone in a place where there's an expectation of privacy. According to previously published reports, the Chatham-Kent Police Service investigated a man after receiving a complaint at the end of January. Police said the man's home was raided and evidence was seized. The charges stem from alleged incidents last summer at the man's home, police said. ___________________________________________________________________ July 26, 2008 Sick wait to join queue at Victoria's public hospitalsGrant McArthur Herald Sun MORE than 33,000 sick Victorians are waiting just to get on an official waiting list for treatment at public hospitals, the Opposition claims. They are in addition to almost 40,000 people already waiting for elective surgery on the State Government's official waiting lists. Documents obtained by the Opposition under Freedom of Information, and seen by the Herald Sun, show that in December last year 33,869 Victorians were waiting for an outpatient appointment. People must be assessed in hospital outpatient clinics before they can be put on a waiting list for surgery - meaning those who are yet to be assessed do not show up on the official elective-surgery waiting lists. Liberal health spokeswoman Helen Shardey said public hospitals were being forced to manipulate waiting lists to avoid being penalised by the Government. "There are literally tens of thousands of patients languishing on the Government's secret outpatient waiting lists and thousands more who don't have appointments who are waiting to get on to these lists to see a doctor," she said. "We are now in the unconscionable position of having people waiting to get on to these lists in order to join the queue for elective surgery. "In many cases these people are waiting years." The documents show that the "secret waiting list" grew by 8722 patients in just three months leading up to December 2007. The Royal Children's Hospital did not provide information, saying the data was not available. Forty-four per cent of those waiting for outpatient appointments are from regional Victoria, with 14,855 people waiting at Ballarat, Barwon, Bendigo and Goulburn Valley Health. One Barwon patient waited four years for an outpatient review appointment to see a specialist about their lymphedema, while two patients had already waited 194 days for oncology appointments at Ballarat Base Hospital. ____________________________________________________________________ July 25, 2008 Paddling team best therapy for breast cancer survivors Dustin Munroe, The StarPhoenix The Busting With Energy (BWE) team is used to moving in unison, both in spirit and in paddle strokes. As the pounding of a dragon boat drum provides the heartbeat for the crew, the BWE team provides a stable rhythm of hope for Saskatoon's breast cancer survivors. The team trains together, competes together and moves forward in the face of adversity. "Our aim as a team is to promote positive energy and let other breast cancer survivors know that there is life after being diagnosed with cancer," said BWE spokesperson Julie Gyoba. "We are living proof of it." The group is splitting up this weekend, for the first time in its 10 years of existence. Half of the team will travel to Dartmouth, N.S., to participate in the Bosom Buddies Atlantic Survivors Dragon Boat Festival. The other half will stay in Saskatoon for the FMG Dragon Boat Festival at Rotary Park. Dartmouth is the furthest BWE has travelled for a dragon boat race. Not everybody could make the long-distance trek. "We try to pick something different each year," said Gyoba. "We try to do one home one and an away one." Edmonton, Regina and Vancouver are a few of the cities the group has visited in past years. The "home team" has recruited friends and relatives to ensure they have a full boat for the FMG races taking place today and Saturday. The 18- person "away team" departed for Nova Scotia, via Regina, on Thursday for competition today through Sunday. The team starts a 12-week training program in February at Bourassa's Physiotherapy. They drop the boat into the water at the edge of Victoria Park for the first time in late May to begin their twice- weekly practice schedule. The complete 41-member BWE group encompasses the many faces of people dealing with breast cancer -- the terminally ill, those undergoing chemotherapy, others who are in physiotherapy to recover from mastectomies and 20-year survivors. They range from 30 to 71 years of age. Some members of the group have fallen, but none have been forgotten. "Since the inception of the team, we have unfortunately lost nine teammates," said Gyoba. "Each meet that we are in, we dedicate it to the memory of the lost teammates." Breast cancer survivors began dragon boating as organized groups in 1996 in Vancouver. Sports medicine physician Dr. Don McKenzie of the University of British Columbia formed the Abreast In A Boat team to test the theory that repetitive upper-body exercise in women treated for breast cancer encouraged lymphedema, a lymphatic system condition. "Initially, after a woman had a mastectomy for breast cancer, they were told not to do any upper-body exercise," said Gyoba. "His research proved the exact opposite, that exercise is the best thing that you can do." No new cases of lymphedema emerged among the participants and none of the existing cases worsened. BWE competed in a race two years ago that marked the 10th anniversary of McKenzie's study in Vancouver. "It was international, with 54 teams from all over the world," said Gyoba. "Dragon boating for breast cancer started in Vancouver and spread worldwide." BWE has expanded in numbers and added fundraising activities to its schedule since its inception, but remains committed to one ideal. "Just to be in the boat, we are all winners," said Gyoba.dsmunroe@sp. canwest.com __________________________________________________________________ July 13, 2008 Women with cancer find help at local store Owner, survivor quit job to follow dream BY DEBBIE KELLEY THE GAZETTE Bobbi Van Riper went on a scavenger hunt after a bout with breast cancer in 1996. She tried to locate a nice wig to cover her balding scalp, compression garments to reduce swelling in her left arm, a swimsuit that fit her post-lumpectomy figure and a remedy for her varicose veins. She eventually found what she wanted, but, as with a scavenger hunt, she had to go from place to place to get everything on her list. Nowhere could she find a convenient, one-stop-shop for her breast cancer needs. So she started one herself: In Care of You. Five years later, about 5,000 survivors of various types of cancer have turned to her Colorado Springs medical boutique to feel better about themselves in a time of hurt, confusion and fear. The shop offers products and services that cater to the particulars of cancer treatment, such as swelling from lymphedema, burns from radiation, hair loss from chemotherapy and disfigurement from breast removal or reconstruction. Need a breast prosthesis, mastectomy bra or swimsuit? The shop has it. How about a synthetic or natural wig, compression garments and pumps or skin-care products to help soothe radiation burns and dryness? You can find those, too. Van Riper even has a makeup specialist on site who does nipple and areola restoration on reconstructed breasts. Although the shop is geared toward women with cancer, any woman in need of a wig, scarves, hats, bras or permanent eyeliner, eyebrows or lip coloring is welcomed. Business has been steady enough for the 12-year breast cancer survivor to purchase an office condo. A few weeks ago, she relocated from a rented, hard-to-find office on North Cascade Avenue to a new, airy space in the Pueblo Bank & Trust building at Pikes Peak and Wahsatch avenues. But Van Riper's business extends beyond sales. She tries to provide an oasis not just for the body, but for the mind as well. The boutique stresses confidentiality and a personal touch, complemented by three staff members who befriend customers, listen to their stories of courage and pain, and freely distribute hugs. They also know what they're doing - all are certified stocking, mastectomy-prosthetics and bra fitters. "Everyone here understands and cares. That's what I wanted - to make a difference in people's lives," Van Riper said. The wig that cancer survivor Lori Woshner purchased from Van Riper greatly improved her life. "The people at In Care of You help you feel as normal as possible, which is very important because it's a long illness," said Woshner, a mother of three. "You're already self-conscious because you've lost your hair. You're going through chemotherapy, so you don't feel so great. I got so many compliments on my new hairstyle - people thought it was my natural hair." Nancy Forgy, a 14-year breast cancer survivor, said she'd been looking for the right bra for more than a decade, after a botched reconstructive surgery. In Care of You ended her search and embarrassment. "Bobbi fitted me for a bra, and I can't tell you how nice it is," Forgy said. "I feel so good." That's exactly the response Van Riper was hoping for when she decided to take a risk and leave her high-paying job as an IBM sales executive to follow her heart and open the medical boutique in 2003. She marketed the concept to local doctors' offices and hospitals and got involved in health fairs. She became certified and registered as a fitter through an industry board and became qualified to accept health insurance from customers, including Medicare and Tricare. Word-of-mouth helped the shop blossom, and with more diagnoses of cancer - one in six Colorado women will fall victim to breast cancer, according to Susan G. Komen for the Cure - the demand is increasing for the shop's products and services. "We now see more mastectomy patients in a day than we used to see in a week," said Van Riper, who also chairs the Colorado Springs Race for the Cure, a fundraiser for breast cancer research, treatment and prevention. "If you can walk out of here and look good, you'll feel good. There is life after breast cancer. People come in here and realize that." CONTACT THE WRITER: 636-0235 __________________________________________________________________ 24 July 2008 Policy guidelines for wound care to be developed Joy Online Accra,Ghana The World Health Organisation, with the support of a specialist group from the US is developing clinical policy guidelines on modern wound care that makes treatment of wound care universal. In an interview with the GNA in Accra on Wednesday after a day’s workshop in Accra on best practices in wound care, Ms. Mary Geyer of the University of Chatham in the USA and a member of the group, said the World Health Organisation (WHO) regarded both modern wound care and lymphedema management as a global imperative and the new knowledge and that technique and material should be made available to developing countries as well. The team is in Ghana to exchange ideas with their Ghanaian counterparts and make room for their input into the formulation of the policy. She said there was the need to include the African practical approach in the policy, adding that, Ghana had a centre of excellence in wound care. Participants made up of plastic surgeons and nurses were taken through topics including Physical Therapy, Current Roles in Wound lymphedema Management, Approach to the Treatment of Diabetes Foot Ulcers and Venous Treatment of Diabetes Leg Ulcers and Modern Wound Care. The mission of the initiative includes education, advocacy and price negotiations with producers of modern dressings as well as identify national experts in wound care and institutions that can be involved in the development of modern wound care practices. Ms Geyer explained that modern wound care and related lymphedema management included leprosy, Buruli Ulcer and common tropical ulcers which had become a vital medical force. She added that the treatment of chronic wound care and lymphedema affected all medical specialties and all ages. More than one billion people in approximately 80 countries live at risk of contracting lymphatic Filariasis, more commonly known as elephantiasis, which is a devastating parasitic infection spread by mosquitoes. Currently over 120 million people are already infected, with more than 40 million incapacitated or disfigured by the disease. __________________________________________________________________ July 20, 2008 Keeping abreast By Dr HARJIT KAUR PERDAMEN What you need to know about breast cancer surgery. WHEN a woman detects a lump or any abnormality in her breast, her whole world often comes to a standstill. A million things run through her mind, especially the possible loss of her breasts. As a result, we often hear women seeking all forms of alternative treatments before finally seeing a breast surgeon. Unfortunately as a result of their unfounded fears and lack of awareness of the therapeutic options available, they usually end up with advanced disease. Breast cancer is still the number one cause of cancer death in Malaysian women, with about 30-35% of women having advanced disease. In an era where technology and skills are constantly advancing, it is truly a sad picture. The reason for this is multi- factorial, the most common being strong religious beliefs and taboos, the immense belief in faith healers, the lack of breast awareness and screening services as well as the lack of trained personnel to provide the necessary services. There are many therapeutic options available to women when they are detected with breast disease. About 80-85% of breast lumps are often benign or non-cancerous. In this group of women, treatment may be surgical or non-surgical. Surgery itself is often minimally invasive without significant cosmetic defect and can be done as a day case. In cases of malignant or cancerous breast lumps, the options are varied depending on many factors. Surgery may be breast-conserving or not. It is when mastectomy (the loss of the whole breast) is discussed as the best option to ensure a safe oncologic outcome that the woman often withdraws into her protective shell. Having to deal with the diagnosis of breast cancer and losing her breasts is often too much for many women to cope with. As a result, many default treatment. Conventional surgeries in breast cancer The most common surgeries carried out in the management of breast cancer are the breast conserving surgery (BCS) and the mastectomy (removal of the entire affected breast). These surgeries may be associated with axillary clearance (removal of the axillary lymph nodes). Although widely accepted as the standard surgical treatment, mastectomy and axillary clearance leaves a woman disfigured and at risk of lymphedema (swelling of the arm). When combined with radiotherapy, the skin changes over the already flattened chest add insult to injury. This in turn affects the women’s self-esteem and confidence. In some cases, women suffer from troubling backaches due to imbalance suffered as a result of the loss of one breast. Oncoplastic surgery as an option Oncoplastic breast surgery is a concept of combining surgery for the cancer together with reconstructive surgery at the same sitting or as a delayed procedure. This option must be made available to any woman who is diagnosed with breast disease that requires a mastectomy or significant tissue loss. Immediate reconstruction after a mastectomy can be done using implants, tissue flaps or a combination of both depending on the suitability of the patient and the oncological criteria. With this technique, a woman will be able to have a reconstructed breast at the same sitting as the mastectomy. This has a tremendous positive impact on a patient’s self-esteem and self-image and is becoming more acceptable in general. A technique called skin sparing mastectomy allows the patient’s skin to be preserved as much as possible. The entire breast tissue and in some instances even the axillary lymph nodes are removed via an incision around the nipple areolar complex. In this way the patient’s natural skin is preserved and reconstruction has a much better cosmetic outcome. In some women, there may be a possibility of preserving the nipple areolar complex as well. This however is case sensitive and strict criteria must be followed. Skin sparing mastectomy can also be combined with tissue flaps like the lattisimus dorsi (LD) flap (back muscle and tissue) and the TRAM flap (where abdominal tissue is used). The choice of reconstruction will very much depend on the best option and patients’ choice. Implant reconstruction with or without the combination of a LD Flap is a safe and short procedure with good outcome. Other tissue flap procedures may be more complicated and lengthy in surgical time and hospital stay. Patients must be given explanations and all the possible options with the risks and complications addressed in detail. The patient finally makes the choice of the procedure with some guidance and advice from her doctor. With the availability of oncoplastic breast surgery, patients have more options and this helps in decision-making about their treatment, thus preventing undue delays that may be detrimental to their prognosis. It is important to highlight here that the oncology aspect of surgery takes precedence over the cosmetics. Hence, it is important for a patient to seek treatment from a doctor who is trained in the field because at no time should the oncological aspect of the surgery be compromised. A multidisciplinary approach in the patient’s management offers the best outcome. Sentinel Node Biopsy (SNB) In all aspects of surgery, we are moving towards minimally invasive procedures. In breast surgery, this is the direction we are heading as well. Sentinel node biopsy is a minimally invasive technique of addressing the axillary lymph nodes and is practised all over the world, mainly in developed countries. SNB is most commonly associated with staging for breast cancer; however it can be used for malignant melanomas (skin cancer). Sentinel is a term derived from the French word sentinelle, which means “to guard over” or “vigilance”. The sentinel node therefore acts as the first filter of malignant cells in the lymphatic system. The technique of SNB is the identification of these sentinel lymph nodes (usually one to three nodes) with the assistance of radioisotopes and dye injections around the tumour. These sentinel nodes are then assessed intra-operatively with the help of frozen sections and is determined of its involvement of cancer cells. If the sentinel lymph nodes are clear of cancer cells, it avoids the patient having a full axillary clearance and all the morbidity associated with it. This procedure requires expertise and experience as well as a competent team in a multidisciplinary setting. It involves a trained breast surgeon, radiologist, pathologist and nuclear medicine facilities. Surgeons who are experienced in SNB can identify the involved node in 85-98% of the patients. The false negative rate is usually less than 5%. The risk of lymphedema (swelling of arm) is very much minimised with this technique. It can be done as a day case, compared to the traditional axillary clearance that involves a post-operative stay of at least three to four days. There is more to breast surgery than meets the eye. The surgical techniques have improved, providing much better outcomes to women affected with breast diseases. Awareness of the availability and options will hopefully get more women to seek treatment early. References: 1. National Cancer Registry 2003 2. Breastcancer.org 3. American Cancer Society Living with Cancer is a monthly column by the Malaysian Oncological Society (MOS) in collaboration with sanofi-aventis Malaysia. For any questions related to this article, please email cancer@malaysiaoncology.org by 27 July 2008. All questions will be answered, but only selected questions will be published the following month. For other enquiries, please visit the MOS website at www.malaysiaoncology.org. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information. __________________________________________________________________ 21 July 2008 Electrothermal vessel sealing effective during mastectomy Source: Reuters Author: David Douglas An electrothermal bipolar vessel sealing system (LigaSure Precise, Valleylab) reduces operative time and appears to be effective in women undergoing modified radical mastectomy with axillary dissection, according to Greek researchers. "Even though modern day surgical management of breast cancer continues to focus appropriately on breast-conserving techniques," Dr. Haridimos Markogiannakis told Reuters Health, "modified radical mastectomy with axillary lymph node dissection remains the most frequently performed surgical procedure for locally advanced breast cancer." In the June issue of the Archives of Surgery, Dr. Markogiannakis and colleagues at the University of Athens note that the approach may engender a variety of complications, including those involving lymph vessel sealing and hemostasis. To see what advantages the electrothermal sealing system might have in this regard, the researchers prospectively studied 60 patients who underwent the same procedure performed by the same surgical team. Intraoperative blood loss ranged from 25 to 70 mL compared to 55 to 332 mL in historical controls. Corresponding ranges for operative time were 80 to 125 minutes and 117 to 210 minutes. For mean mastectomy drainage volume, the figures were five to 40 mL versus 213 to 320 mL. In addition, hospital stay was from three to six days, compared to 2.4 to 10.1 days in controls. There were no postoperative complications in the study group. "Our results," continued Dr. Markogiannakis, "showed that the technique is feasible, safe and effective. The main advantage of the device is that it simplifies the procedure while achieving efficient lymph vessel sealing and hemostasis. This technique seems to result in reduced perioperative blood loss, operative time, drainage volume and duration, and postoperative complications incidence such as seroma or lymphedema." "Further studies," he concluded, "are necessary to evaluate the results of utilization of the device and its impact on perioperative complications." Arch Surg 2008;143:575-580 _________________________________________________________________ July 23, 2008 Doctor awarded diploma honor Dr. Brenda Hallenbeck received a 25-year silver diploma from New York Medical College. Compiled by Azra Haqqie and Lindsey Hollenbaugh TimesUnion.com Hallenbeck graduated from New York Medical College in 1983. She underwent her residency training at Albany Medical Center. She is currently employed at Private Practice Obstetrics and Gynecology in Worcester, Mass. Grant for Slater The USS Slater has received a $350 grant from Stewart's Holiday Match. The money will be used for educational programming aboard the destroyer escort moored on the Hudson River in downtown Albany. Gilda's Club honored Gilda's Club Capital Region has received two national Gracie Awards from the Foundation of American Women in Radio and Television. The awards were presented to Gilda's Club Capital Region and Ann Marie Lizzi, board member, AWRT member and production manager at Time Warner Cable Media Sales, along with other national winners at a luncheon on May 29 at New York City's Tavern on the Green. Funds for cancer program A $6,900 grant from Susan G. Komen for the Cure, a nonprofit network of breast cancer activists, will benefit a St. Peter's Hospital program that helps manage a lymph condition common to breast cancer survivors. The funds have allowed three physical therapists from St. Peter's to attend continuing education programs in lymphedema management. The rest of the money will buy special tape and bandage for about 45 patients who are newly diagnosed with the condition. The sets, which typically cost about $65, allow patients to treat themselves at home. Lymphedema is a chronic condition characterized by swelling of the limbs. Breast cancer survivors whose lymph systems have been compromised by surgery, radiation treatment or lymph node dissection are especially prone to developing lymphedema. The Susan G. Komen Northeastern New York Affiliate serves 11 counties including Albany, Rensselaer, Schenectady and Saratoga. Child dental care funded A $5,000 grant to St. Peter's Hospital and its Ronald McDonald Care Mobile from the Rite Aid Foundation will provide dental care to inner-city children. The traveling dental clinic provides dental care to students at five public schools in Albany. The clinic has been providing care for students at North Albany Academy, Philip J. Schuyler Achievement Academy, Giffen Memorial School, Sheridan Preparatory Academy and Thomas S. O'Brien Academy of Science and Technology. The St. Peter's program also teaches children about brushing and overall oral hygiene. It also provides sports mouth guards; nutritional counseling and demonstrations on proper dental care through videos, interactive games, and reading materials. For more information, call 525-1757 or go to http://www.sphcs.org/dental. CQ Community gardens Capital District Community Gardens will receive $7,456 raised at the third annual Community Resource Father's Day 5K Run and Fun Run for Kids at the Crossings of Colonie. It was organized by Community Resource, in association with the Hudson Mohawk Road Runners Club. Participants were 274 adults and 80 children. The money will help families in need grow their own food in community gardens and access healthy produce on The Veggie Mobile. ___________________________________________ 21 Jul 2008 Bioimpedance Spectroscopy is More Accurate and Reliable Than Other Methods of Subclinical Assessment of Lymphedema in Breast Cancer Patients, According to Paper Published in Journal of Clinical Oncology Author : ImpediMed Bioimpedance spectroscopy (BIS) is more accurate and reliable than other methods of subclinical assessment of lymphedema in breast cancer patients, according to a paper published in the July 20 issue of Journal of Clinical Oncology (2008; Vol. 26, Issue 21: 3536- 3542). Titled "Lymphedema After Breast Cancer: Incidence, Risk Factors, and Effect on Upper Body Function," the paper, authored by Sandra Hayes, PhD., and colleagues from Queensland University of Technology in Australia, is based on a study that involved 265 breast cancer patients. Approximately 87 percent of the patients had undergone lymph node dissection, 70 percent had received radiation therapy and 40 percent had received chemotherapy and/or hormone treatment. The study's investigators conducted assessments of the patients for the evidence of lymphedema at three monthly intervals between six- and 18-months post-surgery using a BIS device, sum of arm circumference (SOAC) and patients' self- reporting. Using BIS, the investigators were able to detect 60 percent of the lymphedema cases that were missed when assessments were conducted with the SOAC method and 40 percent that were missed through self-reporting. For women treated on their non-dominant side, the SOAC method exhibited even lower sensitivity, with approximately eight out of every 10 patients with subclinical lymphedema going undetected. The self-reporting method showed low specificity, with a 40 percent false positive rate (40 percent of patients who did not have lymphedema were reported as having the condition). "Early intervention is critical to the management and treatment of lymphedema, and these latest findings further support the use of bioimpedance spectroscopy as a direct, accurate and reliable measure to aid doctors with the clinical assessment of the condition," said Greg Brown, CEO of ImpediMed, which has the only FDA cleared device for the clinical assessment by health care providers of secondary lymphedema of the arm in women. About Lymphedema Lymphedema is a condition that can cause significant swelling of the upper and lower extremities due to the build-up of excess lymph fluid. This can occur when the lymphatic system, which is responsible for draining excess fluid from the body and is a key component of the immune system, is damaged or altered. In breast cancer patients, this can occur after surgery, such as removal or biopsy of the lymph nodes, and/or radiation therapy. It is estimated that 6 percent to 40 percent of patients with breast cancer develop lymphedema, and that it often occurs within the first two years after surgery. For some cancer survivors and others at risk, a low level lymphedema can occur 10 years to 15 years following the initial primary treatment and develop into a condition that has a serious impact on overall health and quality of life. . About ImpediMed ImpediMed is the world leader in the development and distribution of medical devices employing Bioimpedance Spectroscopy (BIS) technologies for use in the non-invasive clinical assessment and monitoring of human disorders and diseases. ImpediMed's primary product range consists of a number of medical devices that enable surgeons, oncologists, therapists and radiation oncologists to clinically assess patients early for the potential onset of secondary lymphedema. Pre-operative clinical assessment in breast cancer survivors, before the onset of symptoms, may prevent the condition from becoming a lifelong management issue and thus improve the quality of life of the cancer survivor. ImpediMed has the only medical device with FDA clearance in the United States for the clinical assessment, by health care providers, of secondary lymphedema of the arm in women. For more information, visit http://www.impedimed.com. Note: ImpediMed's device is not intended to diagnose or predict lymphedema of an extremity. Contacts: Wendy Lau or David Schull Russo Partners LLC (212) 845-4272 __________________________________________________________________ July 2, 2008 Pre-Operative Assessment of Breast Cancer Patients by Physical Therapists Improves Lymphedema Diagnosis and Treatment ARTEmIS--The Online Magazine of The Breast Center At Johns Hopkins A recent study shows that pre-operative assessments of patients with breast cancer by physical therapists allow for early diagnosis and successful treatment of lymphedema. The study, conducted by the National Naval Medical Center (NNMC) and the National Institutes of Health (NIH) and in collaboration with the University of Michigan-Flint and George Mason University, was published in the journal Cancer. The authors demonstrated the effectiveness of a surveillance program that included pre- operative limb volume measurement and interval post-operative follow-up to successfully detect and treat lymphedema, a chronic and often irreversible condition that can cause significant swelling of the upper and lower extremities due to the build-up of excess lymph fluid. "This study is significant for several reasons, but none more so than it showing that detection and management of lymphedema at early stages may prevent the condition from progressing to a chronic, disabling stage and may enable a more cost-effective, conservative intervention," said American Physical Therapy Association (APTA) spokesperson and the study's lead author, Nicole L Stout Gergich, PT, MPT, CLT-LANA, of the National Naval Medical Center (NNMC) Breast Care Center, in Bethesda, Maryland. Breast cancer related lymphedema is associated with decreased arm function, disability and diminished quality of life. If the condition is not diagnosed early and managed, it can progress to a situation where the patient is at risk for infection and further shoulder complications. The swelling is disfiguring and many times prohibits patients from finding clothes that fit properly. Stout noted that the baseline pre-operative assessment of 196 patients with breast cancer participating in the study - which was conducted from 2001 to 2005 - included basic strength, range of motion, limb volume, and physical activity level. "To measure limb volume, we employed infra-red technology that scans the limbs using beams and sensors, providing us with very accurate information," she said. All study participants were monitored one month post-surgery and at three-month intervals thereafter for one year even if they exhibited no swelling. "Using both the pre- and post-operative assessments enabled us to diagnose lymphedema before it became visible, which is an unprecedented accomplishment," Stout noted. Once lymphedema was diagnosed in 43 of the patients participating in the study, the condition was managed using a conservative compression garment, atypical of lymphedema treatment, observed Stout. A light-grade compression sleeve and gauntlet, fitted by the physical therapist, were prescribed for daily wear. "Lymphedema is normally treated with more aggressive and often costly and time-consuming techniques, such as complete decongestive therapy, which requires the patient to attend daily therapy sessions for weeks and wear bulky compression bandages. This study clearly demonstrates that the condition can be managed with a more conservative treatment option when it is diagnosed at its earliest presentation, which will be good news to breast cancer patients," she added. "What we hope to garner from publicizing this study is that it will encourage patients with breast cancer to ask the questions that need to be asked regarding their treatment, as well as galvanize physicians, surgeons, oncologists and other physical therapists to make early intervention and conservative treatment of lymphedema the standard of care in breast cancer care," Stout concluded. ___________________________________________________________________ _____________________ July 16, 2008 Extension of Therapy Cap Exceptions The Medicare Improvements for Patients and Providers Act of 2008 was enacted on July 15, 2008. One provision of this legislation extends the effective date of the exceptions process to the therapy caps to December 31, 2009. Outpatient therapy service providers may now resume submitting claims with the KX modifier for therapy services that exceed the cap furnished on or after July 1, 2008. For physical therapy and speech language pathology services combined, the limit on incurred expenses is $1810 for calendar year 2008. For occupational therapy services, the limit is $1810. Deductible and coinsurance amounts applied to therapy services count toward the amount accrued before a cap is reached. Services that meet the exceptions criteria and report the KX modifier will be paid beyond this limit. Before this legislation was enacted, outpatient therapy service providers were previously instructed to not submit the KX modifier on claims for services furnished on or after July 1, 2008. The extension of the therapy cap exceptions is retroactive to July 1, 2008. As a result, providers may have already submitted some claims without the KX modifier that would qualify for an exception. Providers submitting these claims using the 837 institutional electronic claim format or the UB-04 paper claim format would have had these claims rejected for exceeding the cap. These providers should resubmit these claims appending the KX modifier so they may now be processed and paid. Providers submitting these claims using the 837 professional electronic claim format or the CMS-1500 paper claim format would have had these claims denied for exceeding the cap. These providers should request to have their claims adjusted in order to have the contractor pay the claim. In all cases, if the beneficiary was notified of their liability and the beneficiary made payment for services that now qualify for exceptions, any such payments should be refunded to the beneficiary. _________________________________________________________________ Posted date: 7/14/2008 ImpediMed Sets Up West Coast Operations Medical Device Maker Seeks Piece of $1B Market By HEATHER CHAMBERS San Diego Business Journal Staff Greg Brown ImpediMed, the maker of a hand-held device used to detect an often debilitating condition in breast cancer survivors who have undergone surgery or radiation treatment, is expanding its U.S. presence with an operations site based in San Diego. The Australian company, which trades under the symbol IPD on the Australian Securities Exchange, is hoping to capture part of the billion-dollar market for detecting a cancer patient’s risk for developing secondary lymphedema, a sometimes painful swelling of the arms and legs caused by trauma to the lymphatic system. Although there is no cure for lymphedema, early detection could help patients better manage their condition and possibly reverse or stop the swelling before it becomes irreversible. Shortly following its listing on the Australian Stock Exchange in October, the company acquired privately held Xitron Technologies Inc. of San Diego for $2.4 million plus $2.85 million in potential milestone payments in order to grow its business in the states. Chief Executive Officer Greg Brown said the acquisition gave ImpediMed access to a ready revenue stream, intellectual property related to its current technologies and a work force of eight people. It also helped the company establish a U.S. operations headquarters in San Diego. The Brisbane-based company also operates a satellite office in New York. “The U.S. market is, by far, the largest market in the world,” Brown said. “If you look at the rest of world, the markets there are very much a different type of health care system and are slower to adopt new technologies than, perhaps, the U.S. market.” ImpediMed reported a net loss of $5.6 million on revenues of $1.2 million for the half-year ended Dec. 31 as compared to a net profit of $3.4 million on revenues of $875,000 for the same period a year earlier. As of March 31, company reports showed it had $10.2 million cash. ImpediMed’s FDA-approved ImpXCA device employs electrical signals to assess fluid changes in the body. The device measures fluid outside the cells to determine whether a patient is at risk for developing lymphedema. According to the National Lymphedema Network, approximately 15 percent to 20 percent of all breast cancer patients are affected by lymphedema in the arms. Pinpointing Risks Today, there is no standard tool used to assess the condition although physicians commonly rely on tape measures and water displacement to track changes in limb size and circumference as well as to report changes in arm mobility. Bioimpedance spectroscopy devices, such as those used by ImpediMed, have been referred to as the next level of detection because of their ease of use and accuracy in determining risk. A study funded by the National Institutes of Health and published online in April in the American Cancer Society’s publication, Cancer, found that breast cancer patients put under lymphedema “surveillance” before and after surgery helped doctors diagnose the condition earlier, resulting in more successful treatment. Dr. Steven Schonholz, a breast surgeon and medical director of the Breast Cancer Center at Mercy Medical Center in Springfield, Mass., uses ImpediMed’s low-frequency device to detect changes in his patients’ fluid levels. ---------------------------------------------------------------------------------------- Aug 26, 2008 City sets tax rates, plans to annex CMU property Constitution-Tribune Chillicothe City Council members set the city’s 2008 tax rates for real and personal property following a public hearing during their regular meeting Monday night at City Hall. The new rate reflects an increase in both the general fund and park fund to produce a modest $4,728 increase in tax revenues. In the general fund, the city approved an increase from 0.6374 to 0.6451 per $100 assessed valuation and in the park fund from 0.1791 to 0.1813 per $100 assessed valuation for an overall increase of just less than a penny per $100 valuation (0.8165 to 0.8264 per $100 assessed valuation). Assessed valuations are down slightly from 2007 to 2008, according to assessment figures. The report shows a slight increase in assessed valuation for real estate at $63,498,018 in 2007 and $63,810,130 in 2008. Assessed valuation for personal property was $26,661,166 in 2007 and $25,841,126 in 2008. Total assessed valuation figures are $90,159,184 in 2007 and $89,651,256 in 2008. Council members on Monday also passed a resolution declaring the intent to annex the Chillicothe Municipal Utilities water treatment property south of Chillicothe. This amounts to 95 acres. The resolution states that the land is an area that is appropriate for incorporating into the city and has been identified as being reasonable and necessary for the physical growth and development of the city. The perimeter of the area is at least 15 percent contiguous to the current city boundary, the resolution stated. The matter must be considered by the city’s planning and zoning board prior to annexation. Also Monday night, council members were introduced to Carole Hobbs, the new director of Hope Haven Industries. Hobbs talked briefly about the services offered by Hope Haven and about the new “e- recycling” program. This program allows the public a free, easy and effective way to dispose of all obsolete or outdated computers, cell phones, printers and much more, either working or not working, that are used in offices, schools, homes and by people on the go. She said Hope Haven accepts almost any small appliance that has a cord. For more information, contact Carole at 646-5172 or 247-1967. In other appearances Monday night, Hedrick Medical Center’s CEO, Brian Johnston, discussed several new services being offered through the hospital. These included lymphedema services which started on Monday, a wound care program which was to begin today (Tuesday) and psychiatric services which are scheduled to start in September. He also said that an ear, nose and throat specialist is coming on board early this fall to provide that service via telemedicine and through on-site clinics and surgeries. Johnston said that the hospital continues its efforts to recruit a second obstetrician/gynochologist, a family practice physician and an internal medicine physician. The hospital is turning 120 years old this year and special events are planned for September, Johnston said........ _________________________________________________________________ August 26, 2008 Massage treatment helps restore mobility Therapy reduces leg swelling from lymphedema Kareem Copeland clarionledger.com Rhoden Hallman goes by the name "Tiny" despite a 6-foot-5, 350-pound frame. What really seemed tiny was a small lump on his left leg in 1971 that turned out to be cancerous. The 75- year-old retired Brandon military man had the lump removed, and then his problems grew. The rare form of soft tissue cancer was synovial sarcoma which affects fat, muscles and commonly develops in the leg. Hallman's options were to either amputate his leg or remove lymph nodes in the area. He obviously wanted to keep his leg but wasn't prepared for the side effects. The lack of lymph nodes led to a condition called lymphedema, a condition where protein-rich fluid builds up in a certain part of the body. It is most commonly found in the extremities but can also affect other parts of the body. The body fights infection by releasing extra fluid to the infected area. The lymphatic system helps drain that fluid. So, with damaged or removed lymph nodes, fluid builds up in the area. Hallman's leg eventually swelled to 30 inches around 10 inches up from the floor. "This has gone on all these years, and I've tried everything you can think of," Hallman said. "Really, no success." Hallman was receiving treatment for a fluid leakage on the leg three months ago at G.V. "Sonny" Montgomery Veterans Affairs Medical Center in Jackson when someone suggested trying complete decongestive therapy. "I said, 'I'm ready for anything,' " Hallman said. "Whatever we need to do." During CDT, a certified lymphedema therapist will stretch the skin using strokes with the hands to route the built up fluid to healthy lymph nodes in other parts of the body that then dispose of the fluid. The method is used in conjunction with compression wraps and garments, delicate skin care to prevent infection, and a series of exercises. Hallman started going to Therapy Solutions at River Oaks Hospital five days a week for two months then dropped down to three days. After three months of treatment, the leg is almost completely normal. "This is just unbelievable," Hallman said. "My balance is better. I can walk better. This thing has just helped me tremendously. "There was a point where I couldn't pick up my leg. Now, I can lay on my back and lift my leg straight up." There is no cure for lymphedema, but the main goal of CDT is to "return the lymphedema to a stage of latency, utilizing remaining lymph vessels and other lymphatic pathways," according to Joachim Zuther's book Lymphedema Management: The Comprehensive Guide for Practitioners. Primary lymphedema develops when a person is afflicted with an abnormal lymphatic system from birth. Secondary lymphedema can develop when a patient's normal lymphatic system is damaged as the result of an external influence such as injury, surgery or radiation that may have occurred recently or happened decades ago. CDT training in the United States began in the 1990s, but was developed in Europe in the 1970s. There are 16 certified lymphedema therapists in Mississippi, and nine practice in the Jackson area. A major problem affecting those with lymphedema is a "pervasive lack of medical expertise in the diagnosis and treatment of this condition and the tendency of clinicians to trivialize lymphedema in patients who have been treated for cancer," Zuther wrote. According to Jill Brady, a certified lymphedema therapist at River Oaks Hospital in Flowood, patients have been treated with diuretics, water pills, compression garments and pneumatic pumps that simply attempt to remove the water backing up in the area. But the fluid is laden with protein, and those methods do not move the mass quantities of protein left behind. "When the protein's sitting there ... they actually attract collagen, what scars are made of," said Brady, who uses Zuther's book in treating the condition. "It's almost like a scar up under the skin ... that starts to be hard. If they don't get the right treatment, besides from the fact that they'll probably be in and out of the hospital with infections, it'll continue to get larger and larger and larger. "It can still be treated, but it takes a lot longer to break down those proteins." To comment on this story, call Kareem Copeland at (601) 961-7190. _________________________________________________________________ August 25, 2008 NUHS: A historic center for Kinesio TapingSource: National University of Health Sciences Ever since members of the U.S. Women's Olympic Volleyball team caught the world's attention with colored tape adorning their skin, people have been buzzing about Kinesio Taping. Kinesio Taping, which was developed by National University of Health Sciences (NUHS) alumni Dr. Kenzo Kase, is a cutting-edge sports medicine technique. Additionally, two NUHS faculty, Vincent De Bono, DC, vice president for Academic Services, and David Parish, DC, dean of clinics, are internationally known educators in this method and are certified Kinesio Taping instructors by Kinesio USA, LLC. Since its development nearly 25 years ago, Kinesio Taping has become the standard for therapeutic taping not only in the U.S., but also in the international practitioner world. This method of taping uses a uniquely designed and patented tape for treatment of muscular disorders and lymphedema reduction. The method and tape allow the individual to wear and receive therapeutic benefits on a 24-hour basis and can be worn for several days per application. The KT method involves taping over and around muscles in order to assist and give muscle support, or to prevent over-contraction of the muscles. The university's current curriculum includes hands-on application of Kinesio Taping during several courses and during students' clinical internship. _________________________________________________________________ August 25, 2008 Hillcrest Womens Center is Best Kept Secret in Tulsa By Kendra Blevins GTR NewsOnline Hillcrest health care system is considered the best place for obstetrics and Women’s care, which is housed in the brand new and state of the art, Peggy V. Helmerich Women’s Health Center. The care at the Women’s Center is like one stop shopping. It offers complete care for women including breast health, gynecology, obstetrics, urology, gynecologic oncology, fertility, and osteoporosis. The Leta M. Chapman Breast Center has the latest technology. The computer aided detection system, (CAD), enhanced visualization film and mammopad, which is a foam mammogram, is “way more comfortable than it used to be,” says Sandra Jackson, executive vice president. “The techs are great at distracting you,” she says. The digital imaging reduces radiation and repeat mammograms. It’s easier to enhance the picture on the new films and they are easily stored so that patients can take their records with them if needed. The center has the only female fellowship trained physician, Lynette Smith in Oklahoma who has her own private office at the Women’s Center. “The message should go out to everyone that Dr. Smith is seeing way too many patients,” says Jackson. “It’s staggering to see how busy she is,” says Delaine Bartsch, administrative director of women’s services. “There are new patients in their twenties, but if there’s an issue get it checked out.” “It’s important to talk freely about breast health. There’s a lot of advance technology here,” says Jackson. She personally answers questions that come in on the Hillcrest website, www.helmerichwomenscenter.com from the “Ask a Nurse” section. Jackson is a registered nurse. “I’ll get a physicians help if I need to. We help people get a doctor if they need one. We don’t want to lose anyone in cyberspace,” says Jackson. She cautions patients to look for only the official websites to find information because there is a lot of misleading information on web. The digital mammography screening and diagnostic offers a double check since a physician and a computer are both analyzing the results. The center offers breast MRI, stereo tactic breast biopsy, breast ultrasound, galactogram, cyst aspiration, PET scans, a lymphedema treatment clinic, a prosthetics salon and certified fitter, mobile mammography van, bone density scans and needle biopsy. The dedicated valet parking in on B1 of the basement level parking and it’s pink so it’s hard to miss the entrance. Adjacent to Hillcrest hospital on 11th and Utica is the Peggy V. Helmerich Women’s Health Center. The center is Eastern Oklahoma’s only hospital dedicated exclusively to women and infants. The center was built in 2003 and designed to have a hotel-style look, feel and amenities. It has dedicated valet parking that shares the same drive as Hillcrest hospital, but the center has it’s own entrance so that expectant mothers can get right in and up to delivery. The birth care center has a state of the art design that is unique to Hillcrest. The rooms are spacious and entirely private with hardwood floors, warm lighting, oversized showers and guest sleeping accommodations. There is a designated play area for children. The Women’s Center is the only hospital in Tulsa to offer couplet-centered care, where the mother and child have the same nurse. The couplet care is unique because it takes a larger staff to provide that kind of care. “ The patients absolutely love it. We do complete care, not traditional. The same nurse cares for mom and baby,” says Bartsch. “Our number one goal is to get mom better and provide education. I appreciate that Hillcrest allows the staff to make that model successful,” she says. The birth care center also provides a labor triage area and early labor lounge. The delivery suites and postpartum suites are close together and the antepartum rooms and neonatal intensive care unit (NICU) are close together. There17 private labor and delivery rooms, 32 private postpartum suites with guest accommodations, seven labor and delivery triage rooms and two cesarean-section rooms. Four board certified maternal fetal medicine physicians work in Women’s center and one is available at all times. The nursery has around the clock security for newborns. Each floor is secured with doors that can only be opened by nurses. Hillcrest has never had an issue with baby theft. The most critical aspect of the center is the NICU. The level three NICU provides the highest level of care and is recognized for the shortest average stay. The 40 bassinets are housed in a quiet environment, with pods that separate each patient for privacy. It is dark with soft sconce lighting. The noise and bright lights of traditional hospitals are not has conducive to development as the state of the art NICU at the Women’s Center. “We remain as developmentally appropriate as we can,” says Bartsch. “It’s awesome when you walk in there, it’s so quiet. The unit is incredible.” There are transition rooms for new parents where they can care for their new baby with a nurse on hand ready to answer any questions. Parents can stay one-two nights in the transition room. “Our nurses are role models for the patients,” says Bartsch. The center has a trained lactation staff that is internationally certified. Breastfeeding is important for the health of the baby and the Women’s Center has 80 percent of mother’s breastfeeding. All the nurses are trained to teach and consult women on breastfeeding. The lactation support team has internationally board-certified lactation consultants. The lactation support team has internationally board-certified lactation consultants. “ The main advantage is our education staff. There is dedicated education for both women and child services. We keep our staff updated and cutting edge,” says Bartsch. The education programs include classes for all parts of preparing for the birth experience: The Healthy Baby Program, Marvelous Multiples, Baby Touch Infant Massage, Breastfeeding Instructions, Infant/Child CPR, Baby- Care Basics and Life In The Womb. “I think our patients feel the difference and go out very happy,” says Bartsch. The Women’s Care Unit provides treatment for urinary incontinence, cancers of the reproductive system, breast cancer, dysfunctional uterine bleeding, endometriosis, and fibroids. It offers the latest multidisciplinary approaches and proven procedures. Hillcrest has all the physicians needed to handle an emergency at anytime of day, night, weekday or weekend. Hillcrest is a teaching hospital with residencies from University of Oklahoma Obstetrics, In His Image Family Practice and OU Family Practice. There are nearly 50 medical residents through the OU College of Medicine. The main benefit of having residencies at Hillcrest is the in house, board certified obstetricians, gynecologists, neonatalogists and neonatal specialists who are available at all times. A physician is always on hand. _________________________________________________________________ August 25, 2008 Medical moversNews-Leader.com Dr. Larry Halverson, a CoxHealth physician, has started a cross-country bike ride of nearly 3,500 miles to raise money and awareness for the Family Medicine Residency Diabetes Fund. The fund is an endowment managed through the CoxHealth Foundation. Halverson, who works with the Cox Family Medicine Residency and Family Medical Care Center, is raising money through donations and pledges. For more about his journey, visit www.coxhealth.com/ridefordiabetes. Thomas A. Martin, a psychologist with the Missouri Rehabilitation Center in Mount Vernon, is the 2008 recipient of the National Academy of Neuropsychology's Early Career Service Award. This award is given annually to one neuropsychologist who has made substantial contributions to the field of neuropsychology within the first 10 years of receiving his or her doctorate. Martin will be honored for the achievement on Oct. 24 in New York City. Martin began his career with University of Missouri Health Care in 2000 and joined Missouri Rehabilitation Center full time in 2002. Marianne Stanley, a massage therapist with Zen 3 Bodywork Studio in Springfield, has received certification in Manual Lymph Drainage (Vodder) through Klose Training via the Scherer Institute of Natural Healing, Santa Fe, New Mexico. Manual Lymph Drainage is a massage technique that helps people with lymphedema and a variety of other conditions. _________________________________________________________________ 19 August 2008 Hypoglycemia Not As Frequently Diagnosed As It WasSource: Sun-Journal Lewiston, Me. Red Orbit DEAR DR. DONOHUE: I was diagnosed with hypoglycemia 25 years ago. I have strictly followed the diet I was instructed to follow, a high- protein, low-carbohydrate diet with six small meals a day. The doctor who made the diagnosis has died, and I have a new one who doesn't believe I have hypoglycemia. He told me I can eat whatever I want. What's your opinion? - R.O. ANSWER: Not so long ago, hypoglycemia - low blood sugar - was an in-vogue condition popularized in many magazines and adopted by many celebrities. It isn't a common disorder, and far too many people were told they had it when they really did not. To make the diagnosis, the following three conditions have to be met: Blood sugar has to be 50 mg/dL (2.8 mmol/L) or less; A person must exhibit the signs and symptoms of low blood sugar at the time blood sugar is low; Giving the person sugar quickly eliminates signs and symptoms. Signs and symptoms of low blood sugar include sweating, tremor, nausea, a fast heartbeat, dizziness, confusion and headache. These things are common to many illnesses, so they aren't distinctive for hypoglycemia. At times, making the diagnosis of hypoglycemia entails hospitalization for a 72-hour fast, during which a battery of blood tests can be done, including measuring blood levels of insulin. When blood sugar is low, insulin production slows. If it remains high, then a pancreatic tumor that's making too much insulin comes under suspicion. Such a tumor is extremely rare. If you feel comfortable on your low- carbohydrate, high-protein diet, there's no reason why you should abandon it. It's a healthy diet. If you would like to try a more liberal diet, do so. The only way to find out what will happen is to experiment. READERS: The often-asked questions about leg and ankle swelling are answered in the booklet on edema and lymphedema. To order a copy, write: Dr. Donohue, No. 106, Box 536475, Orlando, FL 32853- 6475. Enclose a check or money order (no cash) for $4.75 U.S./$6 Can. with the recipient's printed name and address. Please allow four weeks for delivery. DEAR DR. DONOHUE: If I don't use an antiperspirant, I sweat fiercely. I have wet marks on my blouse under my arms. The talk at work is that antiperspirants cause breast cancer and Alzheimer's disease. That scares me. I am waiting for an answer from you before I throw mine out. - K.M. ANSWER: If there were a strong link between antiperspirants and breast cancer and Alzheimer's disease, warnings would be all over the place. There isn't a proven link, and most believe there never will be a proven link. It's the aluminum in antiperspirants that people who promote this idea fixate on. I am not stopping my use of antiperspirants. DEAR DR. DONOHUE: Every evening, my wife and I take a long walk. It's our daily exercise. I attract mosquitoes, but she doesn't. Why? Is there a medical explanation for this? - L.P. ANSWER: People who emit more carbon dioxide than others draw mosquitoes to them. The mosquitoes are attracted by it. Mosquito magnets also have other compounds on their skin that entice mosquitoes. Cholesterol on the skin seems to draw them to a person. Skin cholesterol has nothing to do with blood cholesterol. Uric acid and lactic acid on the skin are other attractants. Mosquito repellent will keep you free of mosquito molestation. DEAR DR. DONOHUE: My sister, 59, has had a problem in her groin area since 1999 and has seen many doctors about it. No one diagnosed her problem until November 2007. It is called celiac disease. All she knows about it is to stay on a gluten-free diet. Can you give more information about the disease and some of the foods she can eat? - G.M. ANSWER: Once thought to be a rare illness, celiac disease is anything but rare. It's an intolerance to gluten, a protein found in wheat, barley and rye. Digestive tract symptoms are its hallmarks: diarrhea, stomach discomfort, bloating and weight loss. However, many symptoms not directly associated with the digestive tract also can occur - things such as anemia, early osteoporosis, iron deficiency, nerve disturbances and a skin condition called dermatitis herpetiformis. Your sister shouldn't be cut adrift with so little information and so few instructions. She needs a dietitian to guide her in how to avoid gluten foods. The Celiac Disease Foundation is a terrific source of information and help. Its phone number is 818-990-2354, and its Web site is www.celiac.org. Have her get in touch with the foundation quickly. The "groin" problem leaves me puzzled. I don't know what that might be or how it might be related to celiac disease. Dr. Donohue regrets that he is unable to answer individual letters, but he will incorporate them in his column whenever possible. Readers may write him or request an order form of available health newsletters at P.O. Box 536475, Orlando, FL 32853- 6475. _______________________________________________________________________________ _ August 25, 2008 Flying with LymphedemaMy Breast Cancer Network by Phyllis Johnson "Flying isn't fun anymore," my brother-in-law frequently proclaims along with other travelers tired of security checks and crowded seats. I certainly agreed with him while I sat on full plane in New Hampshire for an hour waiting for clearance on my way home from visiting our children and new grandbaby. Flying definitely isn't fun anymore for me because I have lymphedema. No one explained it to me at the time, but I was at double risk for this condition that causes swelling because I had 24 lymph nodes removed when I had my mastectomy, and I had extensive radiation to my chest and lymph nodes. Sure enough about a year after my cancer treatment ended, one day I noticed that all the creases in my right wrist were gone. Wow! Did I gain weight that fast? Nope, the creases were still there on the left wrist. The surgeon prescribed a compression sleeve to control the swelling. The sleeve was uncomfortable and didn't help much, but I did get a little better. The next time I saw him, my surgeon told me about a new therapist on the other side of the city who specialized in lymphedema. He would be happy to write a referral if I didn't mind driving so far. An hour's drive through Kansas City traffic versus living with lymphedema? No contest! Having someone who knew the latest research about lymphedema made a real difference. She explained that compression sleeves can maintain progress, but they aren't very good for reducing swelling. Most women need one that has been ordered to their measurements. An off-the-rack sleeve that doesn't fit properly can make the condition worse. Fortunately my lymphedema was still in the mild stage, so she taught me self-massage and bandaging techniques. The bandages wrap the entire arm and make me look like the Michelin man, but they have worked for me. For nine years, my lymphedema has mainly stayed under control. If my arm starts to feel a little tight or if I see swelling, I bandage at night and wear a custom-fitted compression sleeve during the day until it's better. I've had two summers where that wasn't enough when I had to go for massages several times a week and wear the cumbersome bandages all the time except for showering. Getting regular massages is relaxing, if expensive. My insurance expects me to pay the $40 specialist copay for each one. But I consider myself lucky because my therapists have told me that not everyone is able to get lymphedema back under control, and my swelling has never measured higher than moderate on their scale. So what does flying have to do with all of this? The cabin pressure changes that can make your ears pop on an airplane, can also affect lymphedema. Another problem of flying is that all that sitting also encourages fluid build-up. If I don't remember to do some arm exercises, I can see swelling after a long car trip too. My therapist recommends that I bandage before a flight and leave the bandages on for a couple of hours after I get off the plane. I used to bandage before I got to the airport, but since 9/11, I've found that I am more frequently subject to "random" searches when I go through security with a wrapped arm. Now I carry my supplies with me and wrap at the gate. Part of me enjoys watching my fellow passengers' covert glances as they try to figure out what's going on. A woman who looks perfectly healthy takes out a plastic bag and lines up rolls of bandages in various sizes on the seat beside her. I watch them watch me as I tear eight little strips of masking tape and stick them on the handle of my luggage. I pull on a stockinette sleeve and adjust it. Then a foam rubber bandage goes over my thumb and wraps all the way up my arm. After the foam I have four more bandages to wrap, and then I'm ready to fly. Whether breast cancer survivors who have not had lymphedema should wear a compression sleeve when flying seems to be a matter of opinion. If you had an axillary node dissection or if you had radiation to your armpit, it's worth discussing with your doctor or a lymphedema therapist. My therapist says she sees a lot of women who had a lumpectomy and radiation who didn't realize they were at risk for lymphedema because of their radiation. If you had nodes removed AND radiation, then you are at double risk for lymphedema. You'll want to be especially cautious, especially if you are on a long trip with multiple landings and take-offs, or are on a small plane that isn't well pressurized. On this trip, I debated skipping the bandages. Then I remembered that I'd be holding my new grandson when I got to New England. He's definitely worth a few bandages. I'm going to be doing a lot of flying over the next few years to visit him, and I want that arm in good shape for hugs. __________________________________________________________________ AUG 14, 2008 Delayed axillary node dissection not detrimental in breast CA patients with positive sentinel nodes. By Will Boggs, MD Cancerpage.com Delaying axillary node dissection for a few weeks does not appear to be detrimental in breast cancer patients with positive sentinel nodes, according to a report in the July 20th Journal of Clinical Oncology. "Increasingly, women with breast cancer are able to make choices about their treatment," Dr. John A. Olson, Jr. from Duke University Medical Center, Durham, North Carolina told Reuters Health. "While we certainly do not want to turn one operation into two for most women with breast cancer and sentinel node metastasis, these data suggest that taking a stepwise approach to axillary management is a safe and reasonable option for women who do want to consider other options than axillary node dissection." Dr. Olson and colleagues compared pathological results and short-term complications between patients undergoing immediate versus delayed completion axillary lymph node dissection (cALND) after a positive sentinel lymph node biopsy. Timing of cALND was at the discretion of the patient and surgeon. The median interval between sentinel node biopsy and cALND in the delayed group was 19 days (range, 1 to 93 days), the report indicates. In the immediate cALND group, mean tumor size was larger and the rate of estrogen-receptor-negative tumors was greater, compared to the delayed group. Women who underwent immediate cALND had additional nodal metastasis identified 42% of the time, compared with 27% of the time in women who had delayed cALND. Women who underwent immediate cALND also had significantly more total positive lymph nodes and a higher pathologic N stage than did women in the delayed cALND group. Besides immediate cALND, other factors associated with increasing numbers of positive lymph nodes identified on cALND included tumor size, presence of lymphovascular invasion, and more than one positive sentinel lymph node. When complications were compared according to the timing of cALND, axillary paresthesia and impaired range of motion were significantly more common at 30 days (but not at 1 year) in the immediate cALND group, the investigators say. Patients who had delayed cALND had more lymphedema at 6 months, but not at 1 year. "Our data indicate that concern of increased complications in a delayed cALND (compared with immediate cALND) should not be used to justify nonoperative treatment," the authors conclude. But, they point out, "there is considerable added cost and emotional stress to the patient associated with additional surgical procedures, so we emphasize that it is best to use intraoperative sentinel lymph node assessment and perform cALND when sentinel lymph node metastases are found intraoperatively." In his email to Reuters Health, Dr. Olsen added, "Further, in the circumstance where the metastasis is not detected at the initial sentinel node procedure and a return trip to the operating room is needed, there is no clear physical or treatment detriment to the patient other than the potential added cost and concern over a second operative procedure." "We will continue to follow patients in the American College of Surgeons Oncology Group sentinel node trials to determine long-term effects of immediate and delayed axillary dissection," Dr. Olson said. "We are in the planning stages of a study designed to assess cost- effectiveness of the immediate versus delayed approach. We will extend this analysis to compare cost effectiveness of completion axillary dissection versus axillary radiation therapy." __________________________________________________________________ August 08, 2008 Women with family clusters of breast cancer are not necessarily at higher risk No need for women to seek early screeningReuters NEW YORK -- New research suggests that just because a woman has family members with breast cancer, it does not mean that she should undergo early screening for the cancer. According to the report, there are certain factors doctors can look for to determine whether early screening is advisable. "Breast cancer is very common. Familial clustering is also rather common," said Dr. Geertruida H. de Bock, the study's first author,."About 25 to 30 per cent of breast cancer is family clustered, but the [rate] of breast cancer in the family is not very useful in predicting if you will get breast cancer yourself." Having a first- degree relative (mother, sister, or daughter) diagnosed with breast cancer before age 40 is considered to be an indication for starting breast-cancer screening before age 50, de Bock and her team note in the journal BMC Cancer. However, this practice is based on estimates from families with risky gene mutations or who are otherwise cancer-prone. To better understand the risk in the general population, the researchers looked at 1,987 women, all of whom had sisters who had been diagnosed with breast cancer. Some of the study participants had breast cancer while others didn't. The researchers identified four familial factors that were related to developing breast cancer at a younger age: - At least two cases of breast cancer in a first-degree relative. - At least two cases of breast cancer in first or second-degree (grandparent, grandchild, uncle, aunt, nephew, niece, half-sibling) relatives younger than 50. - At least one case of breast cancer in a first or second-degree relative younger than 40. - Any case of cancer affecting both breasts. Women who had at least two of these risk factors were 11 times more likely than those with no risk factors to develop breast cancer by age 30. For cancers occurring before ages 40 and 50, the presence of two or more factors raised the risks by five-fold and two-fold, respectively. However, because breast cancer is so uncommon in younger women, even with two or more of the above factors, the odds of breast cancer by age 30 is just one per cent. By ages 50 and 70, the risks of breast cancer increased to 13 and 11 per cent, respectively. Given that these risks are already pretty low, women with just one factor are likely to have a very low risk and may not require early screening at all. The authors believe that by looking for the factors they identified, doctors can better inform patients of their true risk of breast cancer and whether early screening is warranted. "There is a tendency to screen everyone and I think screening has disadvantages as well as advantages," de Bock said. Doctors "should be critical about it and really think about it if there isn't really an increased risk." _________________________________________________________________ Aug 14, 2008 Norwalk Hospital offers numerous cancer support services By Norwalk Hospital Norwalkplus.com The Whittingham Cancer Center of Norwalk Hospital offers numerous support groups and programs to assist patients with cancer and their families. Our team is committed to working with patients and loved ones in managing the stresses that arise with the diagnosis of cancer, according to Mary-Ellen Loncto, RN, administrative manager of the Whittingham Cancer Center. Arts at the Center is offered on Wednesdays from 10 a.m. to 12 noon. in the Whittingham Cancer Center Conference Room. This program provides patients with stress-free activities emphasizing self-expression and a way to process feelings. Medical Massage is available on Thursdays from 10 a.m. to 1 p.m. Medical massage therapy focuses on symptom management as well as providing a relaxing, gentle type of massage. The Lebed Method is an eight-week class which meets on Mondays from 5:30 p.m. to 6:30 p.m. The Lebed Method is a proven method that reduces the risk of lymphedema. The class is led by certified instructors. Reiki Therapy is offered weekly. Reiki is an ancient art of hands-on healing that eases discomfort, restores balance and sustains health. Anyone interested should call the Cancer Center at (203) 852- 2148 for dates and times. A Bereavement Group meets on Mondays from 5:15 p.m. to 6:45 p.m. in the Whittingham Cancer Center Conference Room. It is a weekly gathering that uses mutual support in working through issues of loss and mourning. The Cancer Support Group meets on Tuesdays from 5:30 p.m. until 7:00 p.m. in the Whittingham Cancer Center's Conference Room. It is an ongoing informal support group to help patients, families and friends cope with cancer. A Nutritionist is available every other Tuesday from 9 a.m. to 11 a.m. Barbara Schmidt, MS, RD, CDN, a Registered Dietitian, helps patients with eating/or digestive issues. Our Kids Group for children ages five through twelve, focuses on the entire family dynamic while living with cancer. This program is for parents and their children. It is co- facilitated by Cancer Care. Music and Meditation meets on the first and third Thursday at 1:45 p.m. to 1: 30 p.m. in the Hospital Chapel in the Hospital Lobby. Individuals may join this group which will explore scripture and music as a way to relax and meditate to promote healing. Requires pre-registration by calling 203-852-2148. The Living with Lymphoma Series is led by one of our oncologists and helps patients and families understand cancer and the treatments for all types of blood cancers. Look Good, Feel Better meets on the first Monday of September, December, March and June. This is a free, non- medical product-neutral program that teaches beauty techniques to women with cancer in active treatment to help them look and feel better. Music Therapy meets every other Tuesday from 1:30 p.m. to 4:30 p.m. in the Cancer Center. Our music therapist visits patients in the infusion room and hospital and plays various types of therapeutic music. Newly Diagnosed Breast Cancer Support Group meets on the second Wednesday of the month at 7 p.m. in the Whittingham Cancer Center Conference Room. The focus of this group is education for the newly diagnosed person Breast Cancer Survivor's Group meets from September to May on the first Wednesday of the month at 5:30 p.m. at the Whittingham Cancer Center. This special support group follows the completion of the initial breast cancer treatment. The Whittingham Cancer Center at Norwalk Hospital also conducts screenings and educational programs to promote early detection of various cancers. For more information on any of these programs or support groups offered as a community service to patients and their families, call the Whittingham Cancer Center at (203) 852-2148. . shtml___________________________________________________________________________ _____ August 13, 2008 Said the Doctor to the Cancer Patient: Hit the Gym By ANAHAD O’CONNOR New York Times AS the group of women trickled into the aerobics studio at the Bendheim Integrative Medicine Center in Manhattan on a recent Thursday morning, there were subtle signs that this was no ordinary fitness class. One woman told the instructor that she had missed a string of previous classes because she was grappling with fatigue, a side effect of her new cancer medication. Others wore colorful wraps on their arms, containment sleeves meant to protect against lymphedema, a painful swelling of the arm stemming from breast cancer surgery. Sponsored by Memorial Sloan-Kettering Cancer Center, this class for cancer patients has been around for some time, mostly in a league by itself. But in recent years, following studies that found exercise to be beneficial in combating the effects of cancer, the class has gained some company. Gyms and fitness centers have begun stepping in to meet a small but growing demand for programs designed to not only hasten recovery but to address the fatigue of chemotherapy, the swelling of lymphedema and the loss of muscle tone. There have always been athletically inclined patients who stayed active, even competitive, in the wake of a diagnosis. A recent high-profile example is Eric Shanteau, an American Olympic swimmer who decided to put off testicular-cancer surgery until he had competed in Beijing. But most of the roughly 10 million cancer survivors in the United States are not amateur Lance Armstrongs. Many, though, are inspired by celebrities like Mr. Armstrong, seeing them as models for how to come out on the other side of often-debilitating treatment regimens. A new program from the Y.M.C.A., in partnership with the Lance Armstrong Foundation, offers cancer fitness classes at more than a dozen Y’s in 10 states. At the women’s gym Curves International, researchers from Fox Chase Cancer Center in Philadelphia are looking at whether overweight breast- cancer patients can keep to a five-day-a-week Curves routine for six months. And survivors are organizing their own classes. “There used to be this understanding that if you’re getting treatment you’re supposed to be in your bed,” said Pam Whitehead, an architect and survivor of uterine cancer who started the Triumph Fitness Program at gyms in Modesto and West Sacramento, Calif. In some cases, oncologists are prescribing exercise, gently prodding patients to tackle whatever activity they can manage: light walking, simple stretches, exercise with resistance bands. “I started in 1992 and that was really a time when not as many patients were exercising,” said Dr. Alexandra Heerdt, a breast surgeon at Sloan-Kettering who is conducting a pilot program involving exercise. “If a patient came to me back then and asked about exercise, I would have said there wasn’t really any information.” But now, she added, “they have a lot of options.” Wendy Rahn, 46, an associate professor of political science at the University of Minnesota, knows this well. After a double mastectomy, her shoulders hurt so much that she was often hunched in pain. Then, while researching her illness, she discovered a 2005 study on cancer and exercise. “The effects — what we call effect sizes in statistical research — were enormous,” she said, “and I was like ‘How come no one is talking about this?’ ” She had given up exercise a decade earlier, but the study inspired her to go back to the gym. “I started feeling so much better,” she said. “And it struck me that if I’m feeling this good, then every cancer survivor should.” So she founded a nonprofit group called Survivors’ Training, and in January opened a fitness studio in White Bear Lake, Minn., offering yoga, strength training, Pilates and Nia, which combines dance and martial arts. “I like to think of it as a support group that moves,” she said. Cancer experts say the shift in thinking began in the mid-1980s, coinciding with a greater awareness of health and fitness. Oncologists were faced with questions about exercise that they had never heard before: how much was allowable and when? Scientists also took notice of studies showing that those who were physically active and eating well were less likely to develop cancer. They then asked what impact exercise and diet would have on those with the disease, said Dr. Charles Fuchs, an oncologist at the Dana-Farber Cancer Institute in Boston who studies cancer and exercise. In the last eight years, a dearth of research has become a flood of studies. Among them is one sponsored by the National Cancer Institute in 2006 that looked at the effects of moderate exercise on groups of breast and prostate cancer patients undergoing radiation therapy for six weeks. Those assigned to a daily program — taking walks of increasing distance and doing exercises with a resistance band — had less fatigue, greater strength and better aerobic capacity than those who were not instructed to exercise. This finding, and similar ones, has been replicated many times. Other studies indicate that moderate exercise has additional benefits like strengthened immune function and lower rates of recurrence. Studies at Dana-Farber found that nonmetastatic colon cancer patients who routinely exercised had a 50 percent lower mortality rate during the study period than their inactive peers, regardless of how active they were before the diagnoses. Dr. Fuchs, a study author, said it influenced his advice. “I am counseling all of my patients to increase their activity,” he said, “or if they were regularly exercising before their diagnosis, to continue.” But every recommendation has its caveats. There will be days during treatment when meaningful activity is not possible, oncologists say, and that’s fine. The American Cancer Society promotes moderate exercise but encourages patients to discuss their exercise plans with their oncologists, and lists on its Web site 13 precautions (cancer .org/docroot/MIT/MIT_0.asp). In the biweekly Focused Fitness class at the Bendheim Integrative Medicine Center in New York, the instructor, Donna Wilson, seeks to ease her charges back into exercise after, and often during, physically draining treatments. Arm extensions and other range-of-motion exercises that can help relieve lymphedema were first on the agenda on a recent morning, followed by heart-pumping lunges and core exercises. A woman who had breast cancer slogged through a set of isometric exercises. “It looks easy,” she said, “but try keeping your arms up all the time when your nerves have been cut.” Ms. Wilson, a registered nurse, encouraged the woman to keep pushing. Then she looked at the class and turned to a visitor. “They’re amazingly strong,” she said. _______ August 7, 2008 Lymphedema after breast cancer surgery common Reuters NEW YORK (Reuters Health) - Lymphedema following breast cancer surgery is a common problem warranting greater attention, clinicians from Australia note in a report in the July 20 issue of the Journal of Clinical Oncology. Among 287 women with invasive breast cancer, 190 participated in all assessments during 18 months of followup after surgery. Lymphedema developed in 62 (33%) of them during that time, Dr. Sandra C. Hayes and colleagues from Queensland University of Technology in Kelvin Grove report. Roughly 60% of these women had transitory symptoms, whereby the lymphedema dissipated with or without treatment. However, 40% of patients experienced long-term lymphedema lasting more than 3 months, with or without intermittent periods of relief. Women with lymphedema, Dr. Hayes told Reuters Health, "were twice as likely to have poorer upper-body function when compared with women who had not developed arm swelling. Poor upper body function is associated with reduced quality of life." More extensive breast surgery increased the odds of lymphedema six-fold, irrespective of extent of axillary dissection. Having more than 20 lymph nodes removed during axillary dissection, irrespective of extent of surgery, increased odds four-fold. Dr. Hayes noted that two identified risk factors for lymphedema -- insufficient physical activity and protection from use of the affected arm -- "are amenable to interventions and should be investigated for their preventive and therapeutic effects among women after treatment for breast cancer." "It was found that use of the treated side likely decreases risk of developing lymphedema," Dr. Hayes said. Lower socioeconomic status, having a partner, greater child care responsibilities, being treated on the dominant side, participation in regular activity and having good upper body function also lowered the odds of lymphedema. "Women at risk for lymphedema, as well as health professionals working with those at risk, should be provided with the education and assistance required for prevention and early detection of lymphedema," Dr. Hayes concluded. _______________________________________________________________________________ _ August 8, 2008 Carle offers new services at business park facility By NATHANIEL WEST, Staff Writer CHARLESTON — They call it the “quad mill.”While your upper body remains vertical and motionless, a gyrating platform works your legs like a mogul field beneath a freestyle skier. You really feel the burn after a minute or so, according to Sean Fadale, director of Carle Therapy Services. It’s one of the few quad mills in this region of the state. “We’re now able to offer some very specialized care,” said Fadale. This machine is part of the enlarged arsenal at the newly opened Carle Foundation facility west of Charleston. In addition to physical therapy and sports medicine services, the renovated building in the Coles Business Park also houses Carle Home Health offices and the soon-to-be-open Carle Sleep Disorders Center. “This investment in the (business park) further demonstrates our commitment (to) Coles County,” said David Cook, vice president of physician practice management for the Carle Foundation. In fact, the relocation of Home Health and Therapy Services to the new center helps with the expansion plans at the Carle Foundation Physician Services clinic east of Mattoon. Therapy Services were housed in modular units on the clinic site, and these units will be removed before Carle raises the walls of a 7,000-square-foot expansion there. In addition to making room at CFPS, the transition to the business park also allows Carle to grow its therapy services, and to bring another sleep disorders center to Coles County (Sarah Bush Lincoln Health Center already operates a sleep lab). Previously, Carle patients suffering from sleep disorders — sleep apnea in most cases — had to travel to Urbana for the overnight sleep study, in which a host of various measuring devices are attached to the patient. A technician in another room monitors breathing, heart rate and movement. The two-bed sleep lab at the business park facility is equipped with infrared lighting and specialized cameras as well. “We’re really proud to be able to provide this service in the community,” said William Vogel, director of pulmonary services at Carle Foundation Hospital. The sleep lab is backed by the Carle Regional Sleep Disorders Center in Urbana; in fact, sleep study participants may use “telemedicine” services at CFPS to communicate with specialists at the Urbana center: During an on-site examination, audio and video data are transmitted to a physician in Urbana. Brenda Ross, manager of the sleep lab, described telemedicine as “a teleconference, but there’s equipment attached so they can do what they’d do in a doctor’s office.” Therapy Services, meanwhile, saw its space triple in size with the relocation to the business park. Along with physical and occupational therapy, speech language pathology, sports medicine and injury evaluation, Carle now boasts such specialty services as occupational rehabilitation; hand rehabilitation; foot therapy; pediatric/development therapy; and a seating and wheeled mobility clinic. Therapy Services also offers lymphedema therapy to combat swelling following damage to the lymphatic system from cancer treatments or injury or surgery involving lymph nodes. “Our job is to get people back to living,” said Fadale. Carle Home Health, comprising Carle Hospice and Carle Home Care, moved into the Park Drive building after Dynamic Homecare in Charleston sold its home care and hospice components to Carle Foundation Hospital in 2007. Home Health’s staff increased by about 75 percent with the move to the business park. It now employs eight nurses, two therapists, a chaplain and other professionals, said Diane Wasson, director of Carle Home Health. Employees also use laptop computers and other technology to work “truly in the community,” said Wasson. Additionally, Carle Home Health operates “Infusion,” in which patients are equipped with portable devices to administer pharmaceuticals that otherwise would require a visit to a hospital or clinic. Contact Nathaniel West at nwest@jg-tc.com or 238-6860. 08-06-2008 CCNC's Dr. Mark Yoffe named a 'Man of The Year' Carolina News Wire RALEIGH, N.C. – Mark Yoffe, MD, a medical oncologist with Cancer Centers of North Carolina (CCNC), was one of seven people in the nation to raise more than $100,000 for The Leukemia & Lymphoma Society’s annual Man & Woman of The Year fundraising event, the society announced this week. Dr. Yoffe was the fifth overall top fundraiser and the fourth top male in the nation. In June, Dr. Yoffe was named Man of The Year of the LLS’s Eastern North Carolina chapter when he set a local record by raising more than $113,000, which automatically entered him into the national contest. “It’s still unbelievable to me that so many people pulled together to make this happen,” Dr. Yoffe said. “I am truly honored to live in such a generous community, and to be a part of the Leukemia & Lymphoma Society’s mission to help find a cure for blood cancers.” The Man & Woman of The Year campaign is a national eight-week fundraising competition between community and business leaders. Dr. Yoffe and his 11 other local competitors raised more than $333,000, another record for the Eastern NC chapter. Also, this group marked the fifth anniversary of the chapter’s Man & Woman of The Year campaign by raising its millionth dollar. Dr. Yoffe’s colleagues and friends at CCNC held numerous events that helped push Dr. Yoffe into the winner’s circle. Geared to his fellow motorcycle enthusiasts, the Rock & Ride featured a bike show, music, food and raffles that included a spin on a bike and lunch with Dr. Yoffe; food and wine connoisseurs enjoyed an evening at Zely & Ritz that raised funds for both Dr. Yoffe and Robin Smith, who later was named Woman of the Year; and tennis lovers – and non-players who wanted to support Dr. Yoffe – came out in force to a tournament held at the Hollow Rock Racquet and Swim Club. A silent auction also was held at CCNC. Dr. Yoffe became active in LLS’s Team in Training (TNT) program in 2004 when he finished the Marine Corps Marathon in honor of his brother and his cancer patients. Dr. Yoffe was the Eastern North Carolina chapter’s top fundraiser for that event as well, raising over $12,000. Dr. Yoffe continues to support LLS as a volunteer speaker at TNT meetings, inspiring others to join in fundraising to help find a cure for blood cancers. About Cancer Centers of North Carolina Cancer Centers of North Carolina (CCNC) has been providing comprehensive cancer care and hematology services in the Greater Triangle area since 1979. Beginning as a single physician practice, originally named Raleigh Hematology Oncology, CCNC has grown to a physician staff of 14 medical oncologists, two radiation oncologists, and the area’s only head and neck surgical oncologist. The practice, which now offers services in five locations throughout the area, provides advanced, state-of-the art diagnostic and therapeutic services, including administration of chemotherapy, biologic and targeted therapies, Computed Tomography (CT), Intensity Modulated Radiation Therapy (IMRT), laboratory and pharmacy services, and an extensive clinical trials program connecting patients to leading cancer investigators around the country. Services are provided in the context of a pleasant, convenient, community-based outpatient setting, where the focus is on patients and their families. CCNC brings the best of medical science and cancer care support services together in one organization, offering chemotherapy and radiation therapy orientation classes, educational resources, nutrition counseling, lymphedema services, physical therapy consultation and fitness programs, yoga, social services, support groups, social services and financial counseling. Practice sites are located in Raleigh, North Raleigh, Cary, Clayton and Dunn. CCNC is an affiliate member of the US Oncology network. US Oncology offers innovative services that help physicians enhance patient access to advanced cancer care in a community setting. For information, call (919)-781-7070 or visit www. CancerCentersofNC.com. About The Leukemia & Lymphoma Society The Leukemia & Lymphoma Society’s Eastern North Carolina chapter serves patients battling leukemia, lymphoma, Hodgkin’s Disease and myeloma in 49 eastern North Carolina counties. The Triangle-based chapter, with a satellite office in Wilmington, raises money for research leading to a cure for blood cancers and to enhance the quality of life for local patients through services such as family support groups, educational programs and financial assistance. For more information, visit www.lls.org or call the chapter office at (919) 677-3993. About US Oncology Inc. US Oncology, headquartered in Houston, supports one of the nation’s foremost cancer treatment and research networks accelerating the availability and use of evidence-based medicine and shared best practices. US Oncology’s expertise in supporting every aspect of the cancer care delivery system – from drug development to treatment and outcomes measurement – enables the company to help increase the efficiency and safety of cancer care. According to the company’s last quarterly earnings report, US Oncology is affiliated with 1,247 physicians operating in 472 locations, including 91 radiation oncology facilities in 39 states. __________________________________________________________ August 6, 2008 Football fundraiser for Oncology Unit BY REBECCA LALLYThe Armidale Express A FESTIVAL of Football will be celebrated in Armidale this month and the beneficiary of the fundraiser will be the local Oncology Unit which helps cancer patients. Funds from the August 24 event will be used to to buy some much-needed equipment for the unit. “We are looking at big ticket items we would never normally get,” said Pam Pateman, the clinical nurse consultant overseeing the Oncology Unit. Among those items are a lymphedema pressure machine, used in some cases to help combat the after effect of cancer treatment, and an auto examination bed that will lift and lower patients without any manual lifting. Pam says that the unit is well supported by the community, but it will be good to have the opportunity to purchase larger items only accessible through a large-scale fundraising event like the festival. The main game of the festival will see a clash between two hand-picked sides led respectively by Northern Tablelands MP Richard Torbay and Armidale and District Football Association president Graham Parsons. The decision to make the Oncology Unit the beneficiary of the festival was made in memory of former football junior competition convenor, Jack Vallance, who died last year and had received great support from the unit. “It’s an honour for us to be dealing with patients and their families in these difficult times,” Pam said. The Kick a Goal For Cancer event will take place at the Rologas Fields on Sunday August 24 and will include a range of games and activities. Another of the highlights will be a penalty shootout open to junior players. __________________________________________________________ August 3, 2008 Dragon Boats Fight Breast Cancer Andy PotterWCAX News The wet weather dampened the turnout a little, but organizers always said the weather would not stop the Dragon Boat races on the Burlington waterfront. This is only the third year that Dragonheart Vermont has hosted an all-day festival on the Burlington waterfront, and already it has become one of the largest events of the year. Dragon Boat races raise money for breast cancer research and patient services, but this is more than a fundraiser. There's a practical benefit. Breast cancer survivors who take part say paddling a dragon boat is actually therapeutic. Mary Anne Eaton of Dragonheart Vermont, said the exercise focused on the arms and upper body helps fight lymphedema, a condition in which excess fluid is retained in the body. "There's also a sisterhood component to this whole dragon boating," she added. "When you are paddling a team and you're surrounded by people who have gone through treatment just like you have, there's a bond that cannot be broken. And the spirit is unbelievable." Most of the paddlers are not cancer patients, but rather cancer patient supporters. And Dragon Boating has gone international. It started some years ago in British Columbia, then spread through Canada and into the United States. Cancer survivors have their own teams. They have made this a true sport with the emphasis on athletic -- and spiritual -- strength. In spite of the rain that fell intermittently through the day, what's heartening to the breast cancer survivors is the tremendous support they have received. Eaton said, "There's this whole community in Burlington, or in Vermont, that have embraced the whole concept behind breast cancer survivors and dragon boating." Linda Dyer, who founded Dragonheart Vermont and put together a team of breast cancer survivors, said, "We go off and race in other places. Last year we got to go to Australia and take part in an all- breast cancer event with 150 teams from around the world. Our dragon boat team just got back from Montreal. We won a gold medal. So we're coming off a big victory from last week, yeah." The breast cancer survivors are the strongest competitors, and so for this event they spread themselves out among all the boats -- to give each crew some added oomph. Some boats performed better than others, but everyone was a winner. __________________________________________________________ Contact: Karen Mallet 414-312-7085 Fox Chase Cancer Center Study suggests some breast cancer patients facing radiation after a mastectomy may be over-treated BOSTON -- A new study suggests standard radiation therapy for some breast cancer patients may not be medically required and may, therefore, be causing unnecessary serious side effects such as lymphedema and pulmonary problems. The research conducted at Fox Chase Cancer Center involved women who got a mastectomy, but whose lymph nodes were negative. "When a woman has a tumor greater than 5 centimeters and negative lymph nodes, a mastectomy followed by radiation is recommended," said Penny Anderson, M.D., attending physician in the radiation oncology department at Fox Chase. "We typically irradiate the chest wall because it's been shown to improve survival. Out of an abundance of caution, many radiation oncologists also treat the surrounding lymph nodes, but there is little evidence that this improves outcome." Irradiation of axillary (under arm) and supraclavicular (above the collarbone) lymph nodes can lead to lymphedema, a swelling of the extremities caused by fluid build up because the nodes which allow the fluids to drain have been damaged by radiation. There are also pulmonary radiation risks including pneumonitis, inflammation, scarring and fibrosis. For the study, Anderson and her colleagues evaluated the need for irradiating these lymph nodes in women whose axillary nodal status following surgery was negative. The study included 64 patients with node-negative breast cancer treated by mastectomy and radiation from 1985-2006. Fifty-three patients received radiation therapy to the chest wall only and 11 patients received radiation to the regional lymph nodes in addition to the chest wall. The median follow-up was 78 months. The results were presented at the 50th annual meeting of the American Society for Therapeutic and Radiology Oncology in Boston. "We found an extremely low rate of recurrences in the lymph nodes among those who didn't have them irradiated," said Anderson. In fact, Anderson added, of the 53 patients that received chest wall radiation but no radiation to the lymph nodes, only one developed a recurrence in an axillary lymph node. None of the patients who received chest wall and node radiation had a recurrence. The 5-year overall survival rates for the two groups were 91 percent for group who received radiation to the chest wall and 100 percent for those who also received radiation to their lymph nodes. There was no statistically significant difference noted between the local, regional or distant recurrence rates between the two groups. "Given these findings and the risks of lymphedema and pulmonary toxicity, avoiding irradiating the lymph nodes may be an acceptable approach in select patients," Anderson concludes. ### In addition to Anderson, other authors include Tianyu Li, Ph.D., Nicos Nicolaou, M.D., and Gary M Freedman, M.D. of Fox Chase Cancer Center. The authors report no disclosures. The study was supported by Fox Chase. Fox Chase Cancer Center is one of the leading cancer research and treatments centers in the United States. Founded in 1904 in Philadelphia as the nation's first cancer hospital, Fox Chase became one of the first institutions to be designated a National Cancer Institute Comprehensive Cancer Center in 1974. Today, Fox Chase conducts a broad array of nationally competitive basic, translational, and clinical research, with special programs in cancer prevention, detection, treatment, and community outreach. For more information, call 1-888-FOX-CHASE or 1-888-369-2427. Awakening the dragon at Octagon Pond The Telegram More than 50 breast cancer survivors and about 300 supporters cheered on the shores of Octagon Pond in Paradise as the Avalon Dragons awakened. In a ceremony to “awaken the dragon” the cancer survivors launched the dragon boat which they built themselves over the last year. There is a strong link between dragon boating and breast cancer — the exercise helps combat lymphedema, a common side effect of breast cancer treatments. For more on this story see Monday's print edition of The Telegram. The Telegram's website will also host a photo gallery of the event starting Monday. ----------------------------------------------------------------------------------- Some Breast Cancer Patients Facing Radiation After A Mastectomy May Be Over-Treated Main Category: Breast Cancer Also Included In: Radiology / Nuclear Medicine Article Date: 23 Sep 2008 - 1:00 PDT A new study suggests standard radiation therapy for some breast cancer patients may not be medically required and may, therefore, be causing unnecessary serious side effects such as lymphedema and pulmonary problems. The research conducted at Fox Chase Cancer Center involved women who got a mastectomy, but whose lymph nodes were negative. "When a woman has a tumor greater than 5 centimeters and negative lymph nodes, a mastectomy followed by radiation is recommended," said Penny Anderson, M.D., attending physician in the radiation oncology department at Fox Chase. "We typically irradiate the chest wall because it's been shown to improve survival. Out of an abundance of caution, many radiation oncologists also treat the surrounding lymph nodes, but there is little evidence that this improves outcome." Irradiation of axillary (under arm) and supraclavicular (above the collarbone) lymph nodes can lead to lymphedema, a swelling of the extremities caused by fluid build up because the nodes which allow the fluids to drain have been damaged by radiation. There are also pulmonary radiation risks including pneumonitis, inflammation, scarring and fibrosis. For the study, Anderson and her colleagues evaluated the need for irradiating these lymph nodes in women whose axillary nodal status following surgery was negative. The study included 64 patients with node-negative breast cancer treated by mastectomy and radiation from 1985-2006. Fifty-three patients received radiation therapy to the chest wall only and 11 patients received radiation to the regional lymph nodes in addition to the chest wall. The median follow-up was 78 months. The results were presented at the 50th annual meeting of the American Society for Therapeutic and Radiology Oncology in Boston. "We found an extremely low rate of recurrences in the lymph nodes among those who didn't have them irradiated," said Anderson. In fact, Anderson added, of the 53 patients that received chest wall radiation but no radiation to the lymph nodes, only one developed a recurrence in an axillary lymph node. None of the patients who received chest wall and node radiation had a recurrence. The 5-year overall survival rates for the two groups were 91 percent for group who received radiation to the chest wall and 100 percent for those who also received radiation to their lymph nodes. There was no statistically significant difference noted between the local, regional or distant recurrence rates between the two groups. "Given these findings and the risks of lymphedema and pulmonary toxicity, avoiding irradiating the lymph nodes may be an acceptable approach in select patients," Anderson concludes. ---------------------------- Article adapted by Medical News Today from original press release. ---------------------------- In addition to Anderson, other authors include Tianyu Li, Ph.D., Nicos Nicolaou, M.D., and Gary M Freedman, M.D. of Fox Chase Cancer Center. The authors report no disclosures. The study was supported by Fox Chase. Fox Chase Cancer Center is one of the leading cancer research and treatments centers in the United States. Founded in 1904 in Philadelphia as the nation's first cancer hospital, Fox Chase became one of the first institutions to be designated a National Cancer Institute Comprehensive Cancer Center in 1974. Today, Fox Chase conducts a broad array of nationally competitive basic, translational, and clinical research, with special programs in cancer prevention, detection, treatment, and community outreach. Source: Karen Mallet Fox Chase Cancer Center p ------------------------------------------------------------------------ Post-Mastectomy Irradiation of Axillary Nodes Unnecessary in Node-Negative Breast Cancer Patients By Jenny Huntington 20:03, September 23rd 2008 3 votes Vote this story During the 50th annual meeting of the American Society for Therapeutic Radiology and Oncology that was held Sunday in Boston, study results showing that nodal radiation of both axillary and supraclavicular lymph nodes is not necessary in women with pathologically node-negative breast tumors that have been previously surgically removed were presented by researchers. Dr. Penny Anderson, attending physician in the radiation oncology department at Fox Chase Cancer Center, Boston, along with her fellow colleagues, looked at 64 women with node-negative breast cancer who had undergone a mastectomy, monitoring them for a period of 78 months. The patients had received radiation treatment follwing the extirpation of a larger than five centimeters breast tumour. Of the women, 53 had radiation therapy only to the chest wall, while the other eleven women underwent, in addition, regional lymph nodes radiation treatment. After evaluation, doctors found that the reoccurence rate for lymph nodes in patients who had not received the additional radiation therapy was very low, only one of the 53 women developing a recurrence in an axillary lymph node. Dr. Penny Anderson stated that, at the moment, radiation treatment following a mastectomy that has removed a 5 or more centimeters large tumor is recommended by most oncologists, although there has not been any cogent evidence that this might improve survival. Moreover, regional node radiotherapy could give rise to pulmonary toxicity and lymphedema, which is also known as lymphatic obstruction, a condition of localized fluid retention that can easily evolve into an infection in the affected limb if it is not treated in due time. The study’s findings come shortly after Canadian researchers revealed that shorter radiation time of about three weeks following a lumpectomy, which is a non-invasive, breast-preserving procedure that involves surgically removing a tumor in a patient’s breast, is as effective as the standard five to seven weeks of chemotherapy. Breast cancer is the second most common type of cancer worldwide after lung cancer, accounting for 10.4% of all cancer incidence. It can affect men and women alike , since both the male and the female breasts are composed of the same tissue. Nevertheless, breast cancer in men is approximately 100 times less common than in women, but the survival rates are the same for both genders. Currently, radiation therapy is standard treatment for women who have undergone either a lumpectomy or a mastectomy. The latter procedure involves removing one or both breast of the patient. The treatment uses high-energy X-rays or gamma rays aimed at killing cancer cells that might remain after the surgical procedure or that could reoccur on the post-surgery tumor site. The treatment is generally given over a period of five to seven weeks, five days a week. Each session lasts about 15 minutes ------------------------------------------------------------------------------ Dangerous Flip-Flops AUBURN, Ala. (Ivanhoe Newswire) -- They might be the unofficial footwear of summer. Millions of pairs of flip-flops are sold every year, and chances are you have at least one pair in your closet; but could your flip-flops be changing the way you walk? "I think there's an attitude that goes with them," one avid flip-flop wearer told Ivanhoe. "Yes, they feel like summer. They're very comfortable to wear." But could flip-flops be a bad thing? Auburn University researchers placed reflective balls on key points of people's legs, then videotaped them and measured vertical force and stride. They found flip-flops significantly changed how people walked. "All the variables that we looked at, there were several that were different between when people walked in flip-flops and when they walked in tennis shoes," Justin Shroyer, a sports medicine researcher at Auburn University in Auburn, Ala., told Ivanhoe. Computer analysis found flip-flop wearers took shorter steps, their heels hit the ground with less force, and they didn't bring their toes up as much. The same toe grip action that keeps flip-flops from falling off may not be so good for you. "What we found is you do change the way you walk, so if you do have lower leg problems, if you do have foot problems, pain, and you wear flip-flops a lot, then maybe reconsider wearing them all the time" Shroyer said. If you can't bear to give up the shoes for good, choose flip-flops with arch and heel support. Only wear them for short amounts of time. Don't wear them if you have to walk far, and when they start to wear out, throw them out. "Once you blow that flip-flop out, don't break out the duct tape and try to fix them," Shroyer said. "Get a new pair." The average American takes between 10 thousand and 20 thousand steps each day, so small changes in one's gait can add up to serious injury. Researchers say sandals with heel straps are a healthier choice because your foot doesn't need to clench to keep the footwear secure. These types of shoes usually offer better arch and heel support as well. FOR MORE INFORMATION, PLEASE CONTACT: Auburn University Auburn, AL ------------------------------------------------------------ FDA approves romiplostim for thrombocytopenia The agency developed a Risk Evaluation and Mitigation Strategy to achieve a positive benefit-risk ratio. The FDA announced on Friday that romiplostim is approved for treatment in both splenectomized and non-splenectomized patients with chronic immune thrombocytopenic purpura. The approval of romiplostim (Nplate, Amgen) was based on safety and efficacy data from two phase-3 trials published in a February issue of the Lancet. Romiplostim is only approved in patients with chronic immune thrombocytopenic purpura and not for patients with myelodysplasia, because of a shown risk in these patients of developing acute leukemia with romiplostim. Safety concerns with romiplostim include fibrous bone marrow deposits and a possible drop in platelet counts after discontinuing romiplostim therapy. Under the FDA Amendments Act of 2007, the FDA has developed a Risk Evaluation and Mitigation Strategy because of the risks associated with romiplostim. This strategy includes a patient medication guide and requires that all patients and prescribers enroll in a long-term safety tracking program. Phase-3 data In the two phase-3 trials, researchers from Massachusetts General Hospital and other sites across the United States and Europe evaluated the safety and efficacy of romiplostim in splenectomized (n=63) and non-splenectomized (n=62) patients with a mean of three platelet counts 30x109/L or less. Patients were randomly assigned to weekly subcutaneous injections of romiplostim (splenectomized study, n=42; non- splenectomized study, n=41) or placebo (n=21) for 24 weeks. Sixteen splenectomized and 25 non-splenectomized patients assigned to romiplostim had a durable platelet response, compared with zero splenectomized and one non-splenectomized patient assigned placebo. The overall platelet response rate was superior for romiplostim in both splenectomized (79%) and non- splenectomized (88%) patients, compared with placebo (splenectomized, n=0 and non-splenectomized, 14%; P<.0001). Patients assigned to romiplostim reached platelet counts of 50x109/L or more for a longer period of time than those assigned to placebo (mean 13.8 weeks vs. 0.8 weeks). Researchers reported a decrease or discontinuation of concurrent therapies, such as corticosteroids, in 87% of patients assigned to romiplostim, compared with 38% of placebo. According to the researchers, mild to moderate adverse events were reported in 95% of patients assigned placebo and 100% of those assigned romiplostim. The most common adverse events in the romiplostim group were headache (35%), fatigue (33%) and epistaxis (32%). –by Stacey L. Adams Lancet. 2008;371:395-403. This approval has been a while in coming and this is the first of several drugs like this that are going to be coming along. This rests on 2 bases: We now recognize that a lot of thrombocytopenia in chronic immune thrombocytopenic purpura is due to a lack of production and not the destruction of circulating platelets. And they’ve now found ways of stimulating the production by imitating thrombopoietin, and this is one of them. This is important because it treats patients who were formerly refractory to the treatments we had, which were often quite dangerous and difficult, and appears to treat them quite readily without serious side effects. Chronic immune thrombocytopenic purpura is a reasonably common problem, so this decision will affect a lot of people. – Wendell Rosse, MD CURRENT PRINT ISSUE Volume 9 Number 15 --------------------------------------------------------------------------- JANUARY 2008 LYMPHEDEMA ABSTRASTS --- Br J Dermatol. 2008 Jan 30 [Epub ahead of print] Lymphatic abnormalities demonstrated by lymphoscintigraphy after lower limb cellulitis.Soo JK, Bicanic TA, Heenan S, Mortimer PS. Department of Dermatology, St George's Hospital, Blackshaw Road, London SW17 0QT, UK. Background Cellulitis is a common cause for admission to hospital, and repeated episodes are thought to damage the lymphatic system. Lymphoedema is recognized as a condition predisposing to cellulitis but there are no data to suggest its prevalence among a population presenting to hospital with acute cellulitis. Objectives To ascertain whether lymphatic abnormalities represent a common problem in patients with lower limb cellulitis. Methods Patients admitted with cellulitis of the lower limb were invited to undergo clinical examination and lymphoscintigraphy. Results Thirty patients agreed to participate in the study. Fifteen underwent lymphoscintigraphy. Thirteen had abnormal scans indicating impaired lymph drainage (seven patients had clinical lymphoedema). Conclusions Lymphatic abnormalities represent an important but unrecognized problem in patients with leg cellulitis. PMID: 18241266 [PubMed - as supplied by publisher] ----------------------------------------------------- AIDS Res Ther. 2008 Jan 29;5(1):2 [Epub ahead of print] The prognostic significance of facial lymphoedema in HIV-seropositive subjects with Kaposi sarcoma. Feller L, Masipa JN, Wood NH, Raubenheimer EJ, Lemmer J. ABSTRACT: BACKGROUND: Kaposi Sarcoma (KS) is a multifocal angioproliferative neoplasm characterized by inflammation, oedema, neoangiogenesis and spindle cell proliferation. The pathogenesis of human immunodeficiency virus (HIV)-associated KS (HIV-KS) is multifactorial and is influenced by HIV, by human herpesvirus-8 (HHV-8), and by increased production of cytokines and growth factors. Whether HIV-KS is a true malignancy or a reactive hyperplastic inflammatory condition is debatable. RESULTS AND CONCLUSIONS: Oedema of the face, legs and hands is a prominent feature of HIV- KS and is probably caused by lymphoedema related to the HIV-KS lesions. The cases of two HIV- seropositive subjects with KS-associated facial lymphoedema are reported. Extensive oral HIV-KS in association with facial oedema in the absence of anti-retroviral treatment appears to be an indication of a poor prognosis. PMID: 18226270 [PubMed - as supplied by publisher] ------------------------------------------------------ Adv Ther. 2008 Jan 28 [Epub ahead of print] Efficacy of etanercept and complete decongestive physical therapy in bilateral lower-limb lymphoedema associated with rheumatoid arthritis: A case report.Eyigor S, Karapolat H, Kirazli Y. Department of Physical Therapy and Rehabilitation, University of Ege, Faculty of Medicine, 35100, Bornova, Izmir, Turkey, eyigor@hotmail.com. A 54-y-old patient with rheumatoid arthritis (RA) and bilateral lower-limb lymphoedema is presented. Complete decongestive physical therapy (CDP) is the cornerstone of the management programme in all patients suffering from lymphoedema associated with RA, but it is not clear which therapy is the most effective in decreasing the oedema. We report on a patient with bilateral lower-limb lymphoedema associated with RA who, after receiving etanercept and CDP, showed moderate improvement. There is little information on the benefit of etanercept therapy for the extra-articular manifestations of RA. Further research is necessary to confirm the beneficial effect of etanercept and CDP. PMID: 18227980 [PubMed - as supplied by publisher] ------------------------------------------------------- Ultrasound Med Biol. 2008 Jan 24 [Epub ahead of print] THE SPATIO-TEMPORAL STRAIN RESPONSE OF OEDEMATOUS AND NONOEDEMATOUS TISSUE TO SUSTAINED COMPRESSION in vivo.Berry GP, Bamber JC, Mortimer PS, Bush NL, Miller NR, Barbone PE. Joint Department of Physics, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK. Poroelastic theory predicts that compression-induced fluid flow through a medium reveals itself via the spatio-temporal behaviour of the strain field. Such strain behaviour has already been observed in simple poroelastic phantoms using generalised elastographic techniques (Berry et al. 2006a, 2006b). The aim of this current study was to investigate the extent to which these techniques could be applied in vivo to image and interpret the compression-induced time-dependent local strain response in soft tissue. Tissue on both arms of six patients presenting with unilateral lymphoedema was subjected to a sustained compression for up to 500 s, and the induced strain was imaged as a function of time. The strain was found to exhibit time-dependent spatially varying behaviour, which we interpret to be consistent with that of a heterogeneous poroelastic material. This occurred in both arms of all patients, although it was more easily seen in the ipsilateral (affected) arm than in the contralateral (apparently unaffected) arm in five out of the six patients. Further work would appear to be worthwhile to determine if poroelasticity imaging could be used in future both to diagnose lymphoedema and to explore the patho-physiology of the condition. (E-mail: gearoid.berry@icr.ac.uk). PMID: 18222033 [PubMed - as supplied by publisher] -------------------------------------------------------------- Am J Physiol Heart Circ Physiol. 2008 Jan 18 [Epub ahead of print] The Resolution of Lymphedema by Interstitial Flow in the Mouse Tail Skin.Uzarski J, Drelles MB, Gibbs SE, Ongstad EL, Goral JC, McKeown KK, Raehl A, Roberts MA, Pytowski B, Smith MR, Goldman J. Biomedical Engineering, Michigan Technological University, Houghton, Michigan, United States. Lymphangiogenesis is considered a promising approach for increasing fluid drainage during secondary lymphedema. However, organization of lymphatics into functional capillaries may be dependent upon interstitial flow (IF). The present study was undertaken to determine the importance of lymphangiogenesis for lymphedema resolution. We created a lymphatic obstruction that produces lymphedema in mouse tail skin. The relatively scar-free skin regeneration that occurred across the obstruction allowed the progression of lymphangiogenesis to be observed and compared with the evolution of lymphedema. The role of VEGF-C/VEGFR-3 signaling in lymphedema resolution was investigated by exogenous administration of VEGF-C or neutralizing antibodies against VEGFR-3. VEGF-C protein improved lymphedema at 15 days (reducing dermal thickness from 742+/-105microm to 559+/-141microm with 95% confidence intervals (CIs), p<0.05) without increasing lymphatic capillary coverage (11.6+/-6.4% following VEGF-C treatment relative to 9.6+/-6.2% with 95% CIs, p>0.50). Blocking VEGFR-3 signaling did not inhibit lymphedema resolution at 25 days (dermal thickness of 462+/-127microm following VEGFR-3 inhibition relative to 502+/-87microm with 95% CIs) or inhibit IF, although VEGFR-3 blocking prevented lymphangiogenesis (reducing lymphatic coverage to 0.2+/-0.7% relative to 8.7+/-7.3% with 95% CIs, p<0.005). A second mouse tail lymphedema model was employed to investigate the ability of VEGF-C to increase fluid drainage across a scar. We found that neither neutralization of VEGFR-3 nor administration of VEGF-C affected the course of skin swelling over 25 days. These findings suggest that resolution of lymphedema in the mouse tail skin may be more dependent upon IF and regeneration of the extracellular matrix across the obstruction than lymphatic capillary regeneration. Key words: lymphatic capillary, lymphangiogenesis, VEGF-C, VEGFR-3, extracellular matrix. PMID: 18203849 [PubMed - as supplied by publisher] ---------------------------------------------------------------- Cancer Res. 2008 Jan 15;68(2):343-5. Acquired lymphedema: an urgent need for adequate animal models.Hadamitzky C, Pabst R. Department of Functional and Applied Anatomy, Hannover Medical School, Hannover, Germany. Hadamitzky.Catarina@MH-Hannover.de In cancer patients, the removal of tumor-draining lymph nodes during tumor resection can lead to acquired lymphedema. This disease, which is characterized by tissue swelling and increased risk of infection due to restricted lymph flow, lacks an effective treatment. Limitations to the design and conduct of randomized trials to date have limited the evaluation of proposed surgical techniques. As a result, animal models have provided an important research base. This review summarizes work in canine, rabbit, and rodent models of acquired lymphedema, focusing on arising limitations and potential applications. PMID: 18199525 [PubMed - indexed for MEDLINE] --------------------------------------------------------------------- Circ Res. 2008 Jan 4;102(1):12-5. Epub 2007 Nov 21. Comment in: Circ Res. 2008 Jan 4;102(1):1-2. Redundant roles for sox7 and sox18 in arteriovenous specification in zebrafish.Herpers R, van de Kamp E, Duckers HJ, Schulte-Merker S. Hubrecht Institute, Uppsalalaan 8, 3584 CT Utrecht, The Netherlands. The specification of arteries and veins is an essential process in establishing and maintaining a functional blood vessel system. Incorrect arteriovenous specification disrupts embryonic development but has also been diagnosed in human syndromes such as hypotrichosis-lymphedema-telangiectasia, characterized by defects in blood and lymphatic vessels and associated with mutations in SOX18. Here we characterize the role of sox7 and sox18 during zebrafish vasculogenesis. Sox7 and sox18 are specifically expressed in the developing vasculature, and simultaneous loss of their function results in a severe loss of the arterial identity of the presumptive aorta which instead expresses venous markers, followed by dramatic arteriovenous shunt formations. Our study identifies members of the Sox family as key factors in specifying arteriovenous identity and will help to better understand hypotrichosis-lymphedema- telangiectasia and other diseases. PMID: 18032732 [PubMed - indexed for MEDLINE] ------------------------------------------------------------------ Am J Phys Med Rehabil. 2008 Jan;87(1):33-8. Reliability study of measurements for lymphedema in breast cancer patients.Chen YW, Tsai HJ, Hung HC, Tsauo JY. School of Occupational Therapy, College of Medicine, National Taiwan University, Taiwan. OBJECTIVE: Water displacement, circumference measurement, and tissue tonometry are important methods to evaluate the status of lymphedemous limbs in breast cancer patients. The purpose of this study was to investigate the reliabilities, and define the limits for clinical change indicative of clinical improvement with respect to these three measures. DESIGN: Fourteen patients were recruited for water displacement and circumference measurement, and 17 for tissue resistance by tonometry. All had been treated for breast cancer and subsequently developed lymphedema. Two physical therapists conducted the measurements to determine intra- and interrater reliability. RESULTS: All measures had fair to excellent reliability (water displacement and circumference measurement, intraclass correlation coefficient [ICC] >0.99, P < 0.05; tissue tonometry, 0.66 < ICC < 0.88, P < 0.05). There was no systematic change in the mean for any of the measures. The variation, as determined by standard error of measurement (SEM), SEM%, smallest real difference (SRD), and SRD% was greatest for tissue tonometry. CONCLUSIONS: Water displacement and circumference measurement (but not tonometry) are reliable techniques for assessing lymphedema in clinical practice. The effect of modifying the tonometry protocol and increasing the amount of rater training should be studied to determine whether the reliability of this method can be improved. PMID: 17993983 [PubMed - indexed for MEDLINE] ---------------------------------------------------------------------- Am J Surg Pathol. 2008 Jan;32(1):72-7. Sporadic cutaneous angiosarcomas: a proposal for risk stratification based on 69 cases.Deyrup AT, McKenney JK, Tighiouart M, Folpe AL, Weiss SW. Department of Pathology, Winship Cancer Institute, Emory University, Atlanta, GA 30322, USA. adeyrup@emory.edu Angiosarcomas have traditionally been considered high-grade lesions for which histologic features and grading have played no role in prognostication and, consequently, they have been excluded from the American Joint Committee on Cancer staging system. We have, therefore, analyzed 69 cutaneous angiosarcomas seen in consultation and not associated with lymphedema or prior radiation therapy to determine if a combination of histologic and clinical parameters could be used to differentiate indolent from aggressive tumors. The clinical features analyzed included patient age, location, size, depth, and focality of the lesion; the histologic features studied included pattern of growth (vasoformative vs. solid), nuclear grade (high vs. low), necrosis (present/absent), cell type (epithelioid or spindled), extent of inflammatory infiltrate (minimal vs. marked), and mitotic rate. Lesions occurred on the head/neck (49), extremities (15), and trunk (5) of adults (21 to 94 y) and predominated in males (41 males; 28 females). Tumors ranged in size from 0.3 to 15 cm (average 3.1 cm) and involved the papillary (n=9), reticular (n=16), or deep dermis/ subcutis (n=30). They could be predominantly vasoformative (n=28) to solid (greater than 50% solid, n=41). Most lesions were of high (n=65) as opposed to low (n=4) nuclear grade, were mitotically active (0 to 99/10 high power fields), and occasionally displayed necrosis (n=14) and epithelioid features (n=21). Inflammatory infiltrates were minimal in most cases. Follow-up information was obtained for all patients. Recurrences developed in 18 patients (26%) and metastasis in 15 (22%) to the following sites: lung (6), lymph node (7), liver (2), bone (2), and parotid gland (1). Forty-seven patients died (30 of disease) and 22 were alive at last known follow-up (range, 16 to 158 mo; mean, 65; median, 36). Five-year disease-specific survival was 48%. By univariate analysis only older age, anatomic site, necrosis, and epithelioid features correlated with increased mortality. Tumors were stratified into low (n=41) or high (n=28) risk groups based on necrosis and/or epithelioid features. By multivariable analysis, high-risk group (hazard ratio 4.07, P=0.0004) and age >70 (hazard ratio 2.79, P=0.012) were associated with increased mortality, and tumor depth (P=0.048) correlated with the risk of local recurrence. The high-risk group had a significantly worse prognosis than the low-risk group with 3-year survival of 24% and 77%, respectively. No patients with high-risk features survived 5 years. In conclusion, we report that a combination of clinical and histologic features allows stratification of angiosarcoma patients into 2 risk groups that are strongly associated with marked differences in clinical course. These features seem to diminish in importance with increased tumor size and are probably most useful in tumors less than 5 cm in maximum dimension. PMID: 18162773 [PubMed - in process] ------------------------------------------------------------------------- Am J Trop Med Hyg. 2008 Jan;78(1):153-8. Collecting baseline information for national morbidity alleviation programs: different methods to estimate lymphatic filariasis morbidity prevalence.Mathieu E, Amann J, Eigege A, Richards F, Sodahlon Y. Division of Parasitic Diseases, National Center of Infectious Diseases, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, GA, USA. emm7@cdc.gov The lymphatic filariasis elimination program aims not only to stop transmission, but also to alleviate morbidity. Although geographically limited morbidity projects exist, few have been implemented nationally. For advocacy and planning, the program coordinators need prevalence estimates that are currently rarely available. This article compares several approaches to estimate morbidity prevalence: (1) data routinely collected during mapping or sentinel site activities; (2) data collected during drug coverage surveys; and (3) alternative surveys. Data were collected in Plateau and Nasarawa States in Nigeria and in 6 districts in Togo. In both settings, we found that questionnaires seem to underestimate the morbidity prevalence compared with existing information collected through clinical examination. We suggest that program managers use the latter for advocacy and planning, but if not available, questionnaires to estimate morbidity prevalence can be added to existing surveys. Even though such data will most likely underestimate the real burden of disease, they can be useful in resource-limited settings. PMID: 18187799 [PubMed - indexed for MEDLINE] --------------------------------------------------------------------------- Ann Surg Oncol. 2008 Jan;15(1):262-7. Epub 2007 Sep 19. Morbidity in breast cancer patients with sentinel node metastases undergoing delayed axillary lymph node dissection (ALND) compared with immediate ALND.Goyal A, Newcombe RG, Chhabra A, Mansel RE. Department of Surgery, School of Medicine, Cardiff University, Cardiff, United Kingdom. goyala@cf.ac. uk BACKGROUND: Patients with sentinel lymph node (SLN) metastases need delayed completion axillary lymph node dissection (ALND) if intraoperative assessment of SLN is not employed. This study was designed to compare morbidity in patients undergoing complete ALND in the first (and only) operation versus those undergoing the two-step procedure (SLN biopsy followed by delayed completion ALND). METHODS: Secondary analysis of the Axillary Lymphatic Mapping Against Nodal Axillary Clearance (ALMANAC) randomized trial compared 83 patients with SLN metastases who proceeded to delayed completion ALND (two-step ALND) with 96 node-positive patients who underwent ALND as the only axillary procedure (one-step ALND). Outcome variables were assessed at baseline and at 3, 6, and 12 months after surgery. RESULTS: The 83 SLN-positive patients undergoing completion ALND were younger (p = 0.038) compared with the one-step ALND group. There was no difference in lymphedema, sensory loss, intercostobrachial (ICB) nerve division rates, impairment of shoulder movement, infection rate, or time to resumption of normal day-to-day activities after surgery between the two groups. Median axillary operative time for completion ALND in the two-step group was significantly higher than one-step ALND (33 min vs. 25 min, p = 0.004). The median hospital stay for the second surgery in the two-step group was similar to one-step ALND (6 days). The total median hospital stay (first and second surgery) was significantly higher for the two-stage procedure (10 vs. 6 days, p < 0.001). CONCLUSION: A two-stage axillary node dissection procedure in patients with SLN metastases has similar arm morbidity to one-stage ALND. The second surgery is associated with increased axillary operative time and total hospital stay. PMID: 17879117 [PubMed - indexed for MEDLINE] ----------------------------------------------------------------------------- Can Fam Physician. 2008 Jan;54(1):81. Top 10 differential diagnoses in family medicine: edema.Ponka D, Kirlew M. Department of Family Medicine at the University of Ottawa in Ontario. dponka@uottawa.ca PMID: 18208962 [PubMed - indexed for MEDLINE ------------------------------------------------------------------------------- Endocr Pract. 2008 Jan-Feb;14(1):109-11. Macromelia masquerading as an acromegaloid syndrome in an adult with Klippel-Trénaunay syndrome. Lowman E, Mooradian AD. Department of Medicine, University of Florida College, Jacksonville, Florida 32209-6511, USA. OBJECTIVE: To describe a case of Klippel-Trénaunay syndrome in an adult patient with symmetric macromelia suggestive of an acromegaloid syndrome. METHODS: We report clinical and laboratory data that were extracted from the medical records of the study patient. We also survey the relevant reports identified through a MEDLINE search of the English-language literature published between January 1, 1996, and June 2, 2007, using the phrase, Klippel-Trénaunay syndrome. RESULTS: A 28- year-old man was admitted to the hospital for weeping lymphedema of the left lower extremity. He had pronounced symmetric hypertrophy of all distal extremities, port-wine stains on his right neck, and varicosities on his left groin. The patient's insulinlike growth factor 1 concentration was 92 ng/mL (reference range, 117-329 ng/mL), which did not support the diagnosis of acromegaly. Klippel- Trénaunay syndrome is a rare congenital condition that belongs to a family of disorders characterized by tissue overgrowth. Classically, the syndrome presents as a triad of vascular malformations, cutaneous hemangiomas, and bone or soft-tissue hypertrophy usually affecting one extremity. The tissue hypertrophy in this syndrome is typically localized and asymmetric. CONCLUSION: The recognition that the tissue hypertrophy in Klippel-Trénaunay syndrome can occur symmetrically will help avoid unnecessary and extensive workup for acromegaly. PMID: 18238750 [PubMed - in process] ---------------------------------------------------------------------------------- J Am Podiatr Med Assoc. 2008 Jan-Feb;98(1):66-9. Elephantiasis nostras verrucosa or "mossy foot lesions" in lymphedema praecox: report of a case. Duckworth AL, Husain J, Deheer P. St. John North Shores Hospital, Harrison Township, MI, USA. Elephantiasis nostras verrucosa is a rare disorder that results from chronic obstructive lymphedema. It is characterized clinically by deforming, nonpitting edema; malodorous hyperkeratosis with generalized lichenification; cobblestoned papules; and verrucous changes, that often result in extreme enlargement of the involved body part. Although elephantiasis nostras verrucosa is striking in clinical appearance, biopsy reveals only moderately abnormal findings: pseudoepitheliomatous hyperplasia with dilated lymphatic spaces in the dermis, accompanied by chronic inflammation and fibroblast proliferation. The term elephantiasis nostras (nostras means "from our region") has traditionally been used to differentiate temperate zone disease from the classic disease process, elephantiasis tropica, which is defined by chronic filarial lymphatic obstruction caused by Wuchereria bancrofti, Wuchereria malayi, or Wuchereria pacifica. We present a case report of elephantiasis nostras verrucosa arising as a result of lymphedema praecox. PMID: 18202337 [PubMed - in process] --------------------------------------------------------------- J Clin Invest. 2008 Jan;118(1):40-50. Adrenomedullin signaling is necessary for murine lymphatic vascular development.Fritz-Six KL, Dunworth WP, Li M, Caron KM. Department of Cell and Molecular Physiology, The University of North Carolina, Chapel Hill, North Carolina 27599, USA. The lymphatic vascular system mediates fluid homeostasis, immune defense, and tumor metastasis. Only a handful of genes are known to affect the development of the lymphatic vasculature, and even fewer represent therapeutic targets for lymphatic diseases. Adrenomedullin (AM) is a multifunctional peptide vasodilator that transduces its effects through the calcitonin receptor-like receptor (calcrl) when the receptor is associated with a receptor activity-modifying protein (RAMP2). Here we report on the involvement of these genes in lymphangiogenesis. AM-, calcrl-, or RAMP2-null mice died mid-gestation after development of interstitial lymphedema. This conserved phenotype provided in vivo evidence that these components were required for AM signaling during embryogenesis. A conditional knockout line with loss of calcrl in endothelial cells confirmed an essential role for AM signaling in vascular development. Loss of AM signaling resulted in abnormal jugular lymphatic vessels due to reduction in lymphatic endothelial cell proliferation. Furthermore, AM caused enhanced activation of ERK signaling in human lymphatic versus blood endothelial cells, likely due to induction of CALCRL gene expression by the lymphatic transcriptional regulator Prox1. Collectively, our studies identify a class of genes involved in lymphangiogenesis that represent a pharmacologically tractable system for the treatment of lymphedema or inhibition of tumor metastasis. PMID: 18097475 [PubMed - in process] ---------------------------------------------------------------- J Surg Oncol. 2008 Jan 1;97(1):74-81. Detection and characterization of vascular endothelial growth factors and their receptors in a series of angiosarcomas.Itakura E, Yamamoto H, Oda Y, Tsuneyoshi M. Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan. BACKGROUND: Angiosarcomas are malignant mesenchymal neoplasms, including sarcomas of presumptive vascular endothelial origin and sarcomas of probable lymphatic origin. It is, however, often difficult to determine whether they are from blood vascular or lymphatic endothelium. The majority of angiosarcomas are thought to originate from vascular endothelia and spread via bloodstream to lung, but lymphatic metastases can occur. METHODS: We investigated immunohistochemical expression of vascular endothelial growth factors (VEGF-A, VEGF-C) and their receptors (VEGFR-1, VEGFR-2, VEGFR-3) in a series of 34 angiosarcomas. RESULTS: VEGF-A was expressed by 32/34 (94%), VEGF-C by 4/34 (12%), VEGFR-1 by 32/34 (94%), VEGFR-2 by 22/34 (65%), and VEGFR-3 by 27/34 (79%). Patients who expressed low or no VEGFR-2 showed a significantly unfavorable prognosis by log-rank test (P = 0.010) and multivariate analysis (hazard ratio, 5.16; 95% CI, 1.40-19.04; P = 0.014). VEGFR-1 and VEGFR-3 were not significantly associated with patients' prognosis. CONCLUSIONS: VEGF-A and VEGFR-1 were detected in diverse subtypes of angiosarcomas. In cooperation, VEGF-A and VEGF-C are likely to be involved in the development of angiosarcoma associated with lymphedema. VEGF-C expression may cause susceptibility to lymphatic metastasis through tumor lymphangiogenesis. Angiosarcoma of the scalp, which is traditionally considered as a true hemangiosarcoma, may include some cases of lymphatic origin. (c) 2007 Wiley-Liss, Inc. PMID: 18041747 [PubMed - in process] --------------------------------------------------------------------- Klin Padiatr. 2008 Jan-Feb;220(1):16-20. Epub 2007 Dec 20. [Chronological age of patients with Turner syndrome at diagnosis][Article in German] Simm D, Degenhardt K, Gerdemann C, Völkl TM, Rauch A, Dörr HG. Kinder- und Jugendklinik, Universität Erlangen-Nürnberg, Germany. BACKGROUND: Phenotypically, Turner syndrome (TS) is characterized by great variability, with short stature being the most constant incidence. Growth hormone therapy can achieve a significant improvement in the final size of the patient, which, however, is highly dependent on early diagnosis of the disease. The objective of our study was to determine the age at which the affected girls among our patient collective were diagnosed with TS and which symptoms were indicative. PATIENTS: The time of diagnosis and the reason for karyotyping were retrospectively determined for 117 girls with TS, who had presented at the Hospital for Children and Adolescents of the University of Erlangen, Germany, in the period between 1980 and 2002. RESULTS: Seven children were prenatally diagnosed with TS by amniocentesis and 27 children were postnatally diagnosed with the disease. TS was diagnosed during infancy in 10 children (median 0.2 years, range 0.1-0.9 yrs.), during early childhood in 4 children (median 1.7 years, range 1.1-2.2 yrs.), and during preschool age in 11 girls (median 5 years, range 4- 5.8 yrs.). In 58 girls, i.e. almost 50%, TS was diagnosed after the age of 6: n=27 between the age of 6 and 11 (median 8.9 years, range 6.1-10.8 yrs.) and n=31 after the age of 11 (median 13 years, range 11.1-17 yrs.). Lymphedema (26 cases), dysmorphic symptoms (14 cases), and heart failures (6 cases) were the reason for karyotyping performed at birth and during infancy. With increasing age, TS was diagnosed based on short stature (66 of 73 cases). CONCLUSIONS: The available data shows that the majority of the patients were diagnosed late and that short stature was the most important diagnostic symptom. PMID: 18095252 [PubMed - in process] ------------------------------------------------------------------------- Microsurgery. 2008;28(2):138-42. Pediatric lymphedema and correlated syndromes: Role of microsurgery.Campisi C, Da Rin E, Bellini C, Bonioli E, Boccardo F. Department of Surgery, Unit of Lymphatic Surgery and Microsurgery, San Martino Hospital, University of Genoa, Italy. Authors report modern diagnostic and therapeutic procedures used in the correct assessment and treatment of congenital lymphatic and chylous disorders. Lymphatic dysplasias can be clinically represented only by peripheral lymphedema or be associated with more complex dysfunctions of chyliferous vessels and the thoracic duct (chylous ascitis, chylothorax, etc.) It is, therefore, useful to perform a complete diagnostic evaluation of each patient before carrying out any therapeutical approach. Lymphoscintigraphy, lymphangio-MR, oil contrast lymphography, and lymphangio-CT are the common diagnostic tools used in these cases, variable associated depending above all on the complexity of the pathology. From the therapeutical point of view, microsurgical methods proved to bring successful and long lasting results, both with derivative lymphatic-venous anastomoses and reconstructive lymphatic- venous-lymphatic anastomoses. Better long-term results are obtained in earlier stages. (c) 2008 Wiley- Liss, Inc. Microsurgery, 2008. PMID: 18220252 [PubMed - in process] --------------------------------------------------------------------------- Oncol Nurs Forum. 2008 Jan;35(1):65-71. Arm morbidity and disability after breast cancer: new directions for care.Thomas-Maclean RL, Hack T, Kwan W, Towers A, Miedema B, Tilley A. Department of Sociology, University of Saskatchewan, Saskatoon, Canada. roanne.thomas@usask.ca PURPOSE/OBJECTIVES: To chart the incidence and course of three types of arm morbidity (lymphedema, pain, and range of motion [ROM] restrictions) in women with breast cancer 6-12 months after surgery and the relationship between arm morbidity and disability. DESIGN: Longitudinal mixed methods approach. SETTING: Four sites across Canada. SAMPLE: 347 patients with breast cancer 6- 12 months after surgery at first point of data collection. METHODS: Incidence rates were calculated for three types of arm morbidity, correlations between arm morbidity and disability were computed, and open-ended survey responses were compiled and reviewed. MAIN RESEARCH VARIABLES: Lymphedema, pain, ROM, and arm, shoulder, and hand disabilities. FINDINGS: Almost 12% of participants experienced lymphedema, 39% reported pain, and about 50% had ROM restrictions. Little overlap in the three types of arm morbidity was observed. Pain and ROM restrictions correlated significantly with disability, but most women did not discuss arm morbidity with healthcare professionals. CONCLUSIONS: Pain and ROM restrictions are prevalent 6-12 months after surgery, but lymphedema is not. Pain and ROM restrictions are associated with disability. IMPLICATIONS FOR NURSING: Screening for pain and ROM restrictions should be part of breast cancer follow-up care. Left untreated, arm morbidity could have a long-term effect on quality of life. Additional research into the longevity of various arm morbidity symptoms and possible interrelationships also is required. PMID: 18192154 [PubMed - indexed for MEDLINE] ------------------------------------------------------------------------------ Oncol Nurs Forum. 2008 Jan;35(1):57-63. Self-reported comorbid conditions and medication usage in breast cancer survivors with and without lymphedema.Ridner SH, Dietrich MS. School of Nursing, Vanderbilt University, Nashville, TN, USA. sheila.ridner@vanderbilt.edu PURPOSE/OBJECTIVES: To compare the self-reported comorbid conditions and medication usage between breast cancer survivors with and without breast cancer treatment-related lymphedema. DESIGN: Descriptive, cross-sectional. SETTING: A community-based study conducted in a major metropolitan area and surrounding rural counties in the southeastern United States. SAMPLE: A convenience sample of 64 breast cancer survivors with lymphedema and 64 breast cancer survivors without lymphedema who were age matched within three years and recruited for a parent study. Twenty- one additional non-age-matched breast cancer survivors with or without lymphedema also were included. METHODS: Self-reported survey instruments and height and weight measurement. MAIN RESEARCH VARIABLES: Lymphedema, demographic information, self-reported comorbid diseases or medical issues, and medication usage. FINDINGS: Breast cancer survivors with lymphedema experienced more comorbid conditions. Statistically significant group differences were found in body mass index, orthopedic issues, cardiac medications, hormone blockers, and osteoporosis medication or calcium supplement usage. Co-occurrence of diabetes and carpal tunnel syndrome approached statistical significance. Breast cancer survivors with lymphedema were older and had lower incomes. CONCLUSIONS: Comorbid conditions may influence the development of breast cancer treatment- related lymphedema. Further research, particularly a longitudinal study, is indicated. IMPLICATIONS FOR NURSING: Healthcare professionals who care for breast cancer survivors need to routinely assess them for the presence of comorbid conditions and the development of lymphedema. Obese breast cancer survivors may benefit from weight reduction interventions to possibly decrease their risk of developing lymphedema and improve their overall health status. Patients with arthritis and orthopedic and cardiac issues such as hypertension may warrant careful monitoring. PMID: 18192153 [PubMed - indexed for MEDLINE] ----------------------------------------------------------------------------------- Ostomy Wound Manage. 2008 Jan;54(1):44-56 Lymphedema in the morbidly obese patient: unique challenges in a unique population.Fife CE, Carter MJ. Department of Anesthesiology, University of Texas Health Science Center, Houston, Texas, USA. Caroline.E.Fife@uth.tmc.edu The population of morbidly obese patients, along with the incidence of lymphedema and massive localized lymphedema associated with this condition, is increasing. A 5-year retrospective review of data (2000-2005) shows that the percentage of patients >350 lb in the authors' clinic population increased from approximately 7% to 11% and 75% of their morbidly obese patients (body mass index >40) had or have lymphedema. After a differential diagnosis between lipedema and lymphedema (primary or secondary) has been made, lymphedema management options include compression bandaging, manual lymphatic drainage, and localized surgeries. The treatment of morbidly obese lymphedema patients requires additional staff time and specialized equipment to move or position them and may be confounded by other conditions (eg, heart failure and venous insufficiency) that contribute to edema. Lymphedema treatments have been found to be useful, providing patients are able to follow treatment guidelines, especially with regard to weight control. In the authors' experience, massive localized lymphedema will recur unless the primary issue of obesity is addressed. Establishing clear criteria and patient participation guidelines before initiating a comprehensive localized lymphedema program will improve outcomes. PMID: 18250486 [PubMed - in process] --------------------------------------------------------------------------------------- Ostomy Wound Manage. 2008 Jan;54(1):20-2, 24-32. A patient-centered approach to treatment of morbid obesity and lower extremity complications: an overview and case studies.Fife CE, Benavides S, Carter MJ. University of Texas Health Science Center, Houston, Texas, USA. Caroline.E.Fife@uth.tmc.edu The prevalence of morbid obesity, along with related comorbidities, is dramatically increasing in the US, confounding wound care for persons at heightened risk for skin compromise. The purpose of this overview is to examine common concerns related to morbid obesity and interrelated lower extremity complications, including wound and skin infections, dermatologic conditions, lymphovenous obstruction syndromes, chronic venous insufficiency, and anatomical abnormalities such as massive localized lymphedema. Treatment may include surgery for massive lymphedema localizations, compression bandaging for chronic venous insufficiency as well as lymphedema, manual lymph drainage for lymphedema, and prompt and aggressive management of wound infection and bioburden. Case studies are presented to illustrate some lower extremity complications of morbid obesity and appropriate protocols of care. Although increasing evidence suggests that morbidly obese patients are predisposed to secondary lymphedema and that primary lymphedema can cause adult-onset obesity, the mechanisms by which these events occur remain unclear. However, unless the underlying problem of morbid obesity is addressed, the problems for which these patients seek care will continue to recur. -------------------------------------------------------------------------------------- FEBRUARY 2008 LYMPHEDEMA ABSTRASTS Arch Gynecol Obstet. 2008 Feb 28 [Epub ahead of print] Recurrence of secondary angiosarcoma in a patient with post-radiated breast for breast cancer.Kunkel T, Mylonas I, Mayr D, Friese K, Sommer HL. First Department of Obstetrics and Gynecology, Ludwig–Maximilians-University Munich, Maistrasse 11, 80337, Munich, Germany. INTRODUCTION: Angiosarcoma of the breast is a rare finding. Two different subtypes of angiosarcomas have been described: (a) the Stewart-Treves syndrome and (b) the cutaneous post- radiation angiosarcoma. We report a case where both types of angiosarcoma occurred. CASE REPORT: At first, an angiosarcoma affecting parenchyma of the breast was observed after radiotherapy following breast conserving therapy and a history of lymphoedema of the radiated area. Additionally, a subsequent local recurrence of the angiosarcoma of the skin after mastectomy and complete resection of the primary angiosarcoma was diagnosed. DISCUSSION: This case is distinguished by a short latency period after primary therapy (less than 4 years) and a rapid recurrence after complete resection (14 weeks). Patients should be pointed to this possible complication of radiotherapy and transferred to seek medical advice immediately in case of skin lesion in the irradiated area: even many years after radiotherapy. Additionally, every oncologist should be aware of this rare complication as quick diagnosis and prompt surgical treatment is indispensable due to the aggressive entity of angiosarcoma. PMID: 18305948 [PubMed - as supplied by publisher] --------------------------------------------------------- Breast Cancer Res Treat. 2008 Feb 24 [Epub ahead of print] Risk factors for arm lymphedema following breast cancer diagnosis in Black women and White women. Meeske KA, Sullivan-Halley J, Smith AW, McTiernan A, Baumgartner KB, Harlan LC, Bernstein L. Department of Preventive Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA. Purpose Lymphedema of the arm is a potential complication of breast cancer therapy. This study examines pre-disposing factors that may operate in conjunction with treatment-related factors in the development of arm lymphedema in a large cohort of White and Black breast cancer survivors. Methods 494 women (271 White and 223 Black) with in situ to Stage III-A primary breast cancer completed a baseline interview within 18 months of diagnosis. Information on lymphedema was collected during a follow-up interview, conducted on average 50 months after diagnosis. Self-reported data were used to classify women with or without lymphedema. Multivariable logistic regression models were developed to identify risk factors for arm lymphedema. Results Arm lymphedema was associated with younger age at diagnosis (odds ratio, OR per year of age = 0.96; 95% confidence interval, CI = 0.93-0.99), positive history of hypertension (OR = 2.31; 95% CI = 1.38-3.88), obesity (OR for body mass index, BMI>/=30 = 2.48; 95% CI = 1.05-5.84) and having had surgery where 10 or more lymph nodes were excised (OR = 2.16; 95% CI = 1.12-4.17). While Black women had higher prevalence of arm lymphedema than White women (28% vs. 21%), race was not associated with lymphedema risk in models adjusted for multiple factors (adjusted OR = 1.01; 95% CI = 0.63-1.63). Conclusion Risk of arm lymphedema did not differ significantly for Black and White women. Risk factors identified in this study offer opportunities for interventions (weight loss, control of blood pressure, use of sentinel node biopsy where possible) for reducing incidence of lymphedema or controlling the symptoms associated with this condition. PMID: 18297429 [PubMed - as supplied by publisher] --------------------------------------------------------------- Orphanet J Rare Dis. 2008 Feb 22;3(1):5 [Epub ahead of print] Primary intestinal lymphangiectasia (Waldmann's disease).Vignes S, Bellanger J. ABSTRACT: Primary intestinal lymphangiectasia (PIL) is a rare disorder characterized by dilated intestinal lacteals resulting in lymph leakage into the small bowel lumen and responsible for protein-losing enteropathy leading to lymphopenia, hypoalbuminemia and hypogammaglobulinemia. PIL is generally diagnosed before 3 years of age but may be diagnosed in older patients. Prevalence is unknown. The main symptom is predominantly bilateral lower limb edema. Edema may be moderate to severe with anasarca and includes pleural effusion, pericarditis or chylous ascites. Fatigue, abdominal pain, weight loss, inability to gain weight, moderate diarrhea or fat-soluble vitamin deficiencies due to malabsorption may also be present. In some patients, limb lymphedema is associated with PIL and is difficult to distinguish lymphedema from edema. Exsudative enteropathy is confirmed by the elevated 24-h stool alpha-1 antitrypsin clearance. Etiology remains unknown. Very rare familial cases of PIL have been reported. Diagnosis is confirmed by endoscopic observation of intestinal lymphangiectasia with the corresponding histology of intestinal biopsy specimens. Videocapsule endoscopy may be useful when endoscopic findings are not contributive. Differential diagnosis includes constrictive pericarditis, intestinal lymphoma, Whipple's disease, Crohn's disease, intestinal tuberculosis, sarcoidosis or systemic sclerosis. Several B-cell lymphomas confined to the gastrointestinal tract (stomach, jejunum, midgut, ileum) or with extra-intestinal localizations were reported in PIL patients. A low-fat diet associated with medium-chain triglyceride supplementation is the cornerstone of PIL medical management. The absence of fat in the diet prevents chyle engorgement of the intestinal lymphatic vessels thereby preventing their rupture with its ensuing lymph loss. Medium-chain triglycerides are absorbed directly into the portal venous circulation and avoid lacteal overloading. Other inconsistently effective treatments have been proposed for PIL patients, such as antiplasmin, octreotide or corticosteroids. Surgical small-bowel resection is useful in the rare cases with segmental and localized intestinal lymphangiectasia. The need for dietary control appears to be permanent, because clinical and biochemical findings reappear after low-fat diet withdrawal. PIL outcome may be severe even life-threatening when malignant complications or serous effusion(s) occur. PMID: 18294365 [PubMed - as supplied by publisher] ------------------------------------------------------------------- J Clin Oncol. 2008 Feb 20;26(6):884-9. Comment in: J Clin Oncol. 2008 Feb 20;26(6):828-9. Sentinel node dissection is safe in the treatment of early-stage vulvar cancer.Van der Zee AG, Oonk MH, De Hullu JA, Ansink AC, Vergote I, Verheijen RH, Maggioni A, Gaarenstroom KN, Baldwin PJ, Van Dorst EB, Van der Velden J, Hermans RH, van der Putten H, Drouin P, Schneider A, Sluiter WJ. Department of Obstetrics and Gynecology, University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, the Netherlands. a.g.j.van.der.zee@og.umcg.nl PURPOSE: To investigate the safety and clinical utility of the sentinel node procedure in early-stage vulvar cancer patients. PATIENTS AND METHODS: A multicenter observational study on sentinel node detection using radioactive tracer and blue dye was performed in patients with T1/2 (< 4 cm) squamous cell cancer of the vulva. When the sentinel node was found to be negative at pathologic ultrastaging, inguinofemoral lymphadenectomy was omitted, and the patient was observed with follow-up for 2 years at intervals of every 2 months. Stopping rules were defined for the occurrence of groin recurrences. RESULTS: From March 2000 until June 2006, a sentinel node procedure was performed in 623 groins of 403 assessable patients. In 259 patients with unifocal vulvar disease and a negative sentinel node (median follow-up time, 35 months), six groin recurrences were diagnosed (2.3%; 95% CI, 0.6% to 5%), and 3-year survival rate was 97% (95% CI, 91% to 99%). Short-term morbidity was decreased in patients after sentinel node dissection only when compared with patients with a positive sentinel node who underwent inguinofemoral lymphadenectomy (wound breakdown in groin: 11.7% v 34.0%, respectively; P < .0001; and cellulitis: 4.5% v 21.3%, respectively; P < .0001). Long-term morbidity also was less frequently observed after removal of only the sentinel node compared with sentinel node removal and inguinofemoral lymphadenectomy (recurrent erysipelas: 0.4% v 16.2%, respectively; P < .0001; and lymphedema of the legs: 1.9% v 25.2%, respectively; P < .0001). CONCLUSION: In early-stage vulvar cancer patients with a negative sentinel node, the groin recurrence rate is low, survival is excellent, and treatment-related morbidity is minimal. We suggest that sentinel node dissection, performed by a quality-controlled multidisciplinary team, should be part of the standard treatment in selected patients with early-stage vulvar cancer. PMID: 18281661 [PubMed - indexed for MEDLINE] --------------------------------------------------------------------- Cancer. 2008 Feb 15;112(4):950-4. Manipulative therapy of secondary lymphedema in the presence of locoregional tumors.Pinell XA, Kirkpatrick SH, Hawkins K, Mondry TE, Johnstone PA. Radiation Oncology Department, Emory University School of Medicine, Atlanta, Georgia, USA. BACKGROUND: Complete decongestive therapy (CDT), including manual lymphatic drainage (MLD) is a manipulative intervention of documented benefit to patients with lymphedema (LE). Although the role of CDT for LE is well described, to the authors' knowledge there are no data regarding its efficacy for patients with LE due to tumor masses in the draining anatomic bed. Traditionally, LE therapists are wary of providing therapy to such patients with 'malignant' LE for fear of exacerbating the underlying cancer, and that the obstruction will render therapy less effective. In the current study, the authors' experience providing CDT for such patients is discussed. METHODS: Cancer survivors with LE were referred to therapists at 2 Atlanta-area clinics. CDT consists of treatment (Phase 1) and maintenance phases (Phase 2). During Phase 1, the patient undergoes manipulative therapy and bandaging daily until the LE reduction plateaus; at that point, Phase 2 (self-care) begins. At the beginning and end of Phase 1, LE is quantified and differences in girth volume calculated. The results for patients completing Phase 1 therapy for LE in the presence of locoregional masses were compared with results for patients with LE in the absence of such disease. Both volume reduction of the affected limb and number of treatments to plateau were analyzed. RESULTS: Between January 2004, and March 2007, LE of 82 limbs in 72 patients was treated with CDT and Phase 1 was completed. The median number of treatments to plateau was 12 (range, 4-23 treatments); the median limb volume reduction was 22% (range, -23 to 164%). Nineteen limbs (16 patients) with associated chest wall/axillary or pelvic/inguinal tumors had nonsignificant difference in LE reduction (P = .75) in the presence of significantly more sessions to attain plateau (P = . 0016) compared with 63 limbs in 56 patients without such masses. CONCLUSIONS: Patients with LE may obtain relief with CDT regardless of whether they have locoregional disease contributing to their symptoms. However, it will likely take longer to achieve that effect. Manipulative therapy of LE should not be withheld because of persistent or recurrent disease in the draining anatomic bed. Cancer 2008. (c) 2007 American Cancer Society. PMID: 18085587 [PubMed - in process] ----------------------------------------------------------------------- Breast Cancer Res Treat. 2008 Feb 13 [Epub ahead of print] Lymphatic venous anastomosis (LVA) for treatment of secondary arm lymphedema. A prospective study of 11 LVA procedures in 10 patients with breast cancer related lymphedema and a critical review of the literature.Damstra RJ, Voesten HG, van Schelven WD, van der Lei B. Department of Dermatology, Phlebology and Lymphology, Nij Smellinghe Hospital, Compagnonsplein 1, 9202 NN, Drachten, The Netherlands, r.damstra@nijsmellinghe.nl. Objective The incidence of breast cancer related lymphedema (BCRL) varies between 7-35% depending on the combination of treatment modalities. Early detection of BCRL is crucial in order to start an effective non-operative treatment program. Because of the lack of prospective research on this topic, this study was undertaken to prospectively determine the effect of Lympho Venous Anastomosis (LVA) on BCRL and to review the current literature. Study design and methods Ten patients who were previously treated for breast cancer by surgery, radiotherapy, and chemotherapy, and were unresponsive to 12-weeks of non-operative treatment, underwent an LVA procedure (Degni-Cordeiro). Objective measurements were gathered for circumferential measurement and water volumetry, and quality of life. Various types of lymphoscintigraphy were carried out pre-operatively and post-operatively at 3 and 12 months. Treatment was embedded in a multidisciplinary setting. Results Post-operative volume measurements initially showed a 4.8% reduction of lymphedema at 3 months and a 2% reduction after one year. Various scintigraphic parameters showed some improvement. Quality of life questionnaires reported minimal improvement. Reviewing the literature, only retrospective studies were found; these reported varying results for LVA procedures. The selection of patients, classification of lymphedema, indications and types of LVA, and additional therapeutic options were heterogeneous, not comparable, and lacked a validated method of effect-assessment. Conclusions Our results showed a minimal reduction in volume of lymphedema following LVA; in the literature, there was no convincing evidence of the success of LVA. Non-operative treatment and elastic stockings are still preferred by most patients with lymphedema, especially in early stages with few irreversible changes. PMID: 18270813 [PubMed - as supplied by publisher] ----------------------------------------------------------------------- JAMA. 2008 Feb 13;299(6):632-3; author reply 633. Comment on: JAMA. 2007 Oct 24;298(16):1911-24. Treatment for lymphatic filariasis and elephantiasis.Fox L, Beach MJ, Lammie PJ. PMID: 18270350 [PubMed - indexed for MEDLINE] ---------------------------------------------------------------- J Clin Oncol. 2008 Feb 10;26(5):759-67. Implementing a survivorship care plan for patients with breast cancer.Ganz PA, Hahn EE. Division of Cancer Prevention and Control Research, Jonsson Comprehensive Cancer Center, 650 Charles Young Dr South, Room A2-125 CHS, Los Angeles, CA 90095-6900, USA. pganz@ucla.edu Breast cancer survivors account for 23% of the more than 10 million cancer survivors in the United States today. The treatments for breast cancer are complex and extend over a long period of time. The post-treatment period is characterized by gradual recovery from many adverse effects from treatment; however, many symptoms and problems persist as late effects (eg, infertility, menopausal symptoms, fatigue), and there may be less frequent long-term effects (eg, second cancers, lymphedema, osteoporosis). There is increasing recognition of the need to summarize the patient's course of treatment into a formal document, called the cancer treatment summary, that also includes recommendations for subsequent cancer surveillance, management of late effects, and strategies for health promotion. This article provides guidance on how oncologists can implement a cancer treatment summary and survivorship care plan for breast cancer survivors, with examples and linkage to useful resources. Providing the breast cancer treatment summary and survivorship care plan is being recognized as a key component of coordination of care that will foster the delivery ---------------------------------------------------------- Clin Appl Thromb Hemost. 2008 Feb 8 [Epub ahead of print] Gastric Signet-Ring Cell Adenocarcinoma Presenting With Left Arm Deep-Vein Thrombosis and Bilateral Chylothorax.Kayacan O, Karnak D, Can BA, Sak SD, Beder S. Ankara University School of Medicine. A 28-year-old housewife, a life-long nonsmoker, presented with 3 weeks of pleuritic chest pain along with swollen right leg, left arm, and left breast. Six months previously she had left subclavian vein thrombosis. On admission, bilateral supraclavicular lymphedema on right leg and left arm and breast was observed and bilateral pleural fluid, chylous exudates, was detected. Abdomen computed tomography revealed abundant ascites and right ovarian enlargement. Whole body bone scintigraphy showed bone metastases on left humerus, right femur, and pelvis. Bronchial biopsy, obtained from edematous, hyperemic-irregular mucosa, revealed a carcinoma composed of signet-ring cells with intracytoplasmic mucin. Breast biopsy also showed signet-ring cells within the lymphatics. Pleural fluid cytology showed similar malignant cells. The patient was diagnosed as gastric signet-ring cell adenocarcinoma with endobronchial, mammary, ovarian, pleural, pericardial, peritoneal, and osteal metastases. The authors recommend that deep-vein thrombosis in unusual sites deserves further evaluation for an occult malignancy. PMID: 18263634 [PubMed - as supplied by publisher] -------------------------------------------------------------- Gynecol Oncol. 2008 Feb 4 [Epub ahead of print] Isolated sentinel lymph node dissection with conservative management in patients with squamous cell carcinoma of the vulva: A prospective trial.Moore RG, Robison K, Brown AK, Disilvestro P, Steinhoff M, Noto R, Brard L, Granai CO. Program in Women's Oncology, Women and Infants' Hospital, Brown University, Providence, RI, USA. OBJECTIVES: Sentinel lymph node (SLN) dissections have a high sensitivity and negative predictive value for the detection of metastatic disease. The objective of this study was to examine the inguinal recurrence rate along with complication rates for patients undergoing inguinal SLN dissection alone for vulvar carcinoma. METHODS: An IRB approved prospective study enrolled patients with biopsy proven squamous cell carcinoma of the vulva. Peritumoral injection of Tc-99 sulfur colloid and methylene blue dye was used to identify SLNs intraoperatively. Patients with SLNs negative for metastatic disease were followed clinically. Patients with metastasis detected in a SLN subsequently underwent a full groin node dissection followed by standard treatment protocols. RESULTS: Thirty-six patients were enrolled onto study with 35 undergoing a SLN dissection. All SNL dissections were successful with a mean of 2 SLN obtained per groin. There were 24 patients with stage I disease, 8 stage II, 3 stage III and 1 stage IV. A total of 56 SLN dissections were performed with 4 patients found to have inguinal metastasis by SLN dissection. There were 31 patients with a total of 46 SLN dissections found to be negative for metastatic disease. The median follow-up has been 29 months (range 8 to 51) with 2 groin recurrences for a groin recurrence rate of 4.3% and a recurrence rate per patient of 6.4%. There have been no reports of groin breakdown, extremity cellulitis or lymphedema. CONCLUSIONS: The recurrence rate for patients undergoing inguinal sentinel node dissection alone is low. These patients did not experience any complications as seen with complete groin node dissections. Sentinel lymph node dissection should be considered as an option for evaluation of inguinal nodes for metastatic disease. PMID: 18255128 [PubMed - as supplied by publisher] --------------------------------------------------------------- Am J Dermatopathol. 2008 Feb;30(1):67-72. Otophyma: a case report and review of the literature of lymphedema (elephantiasis) of the ear.Carlson JA, Mazza J, Kircher K, Tran TA. Division of Dermatology, Albany Medical College, 47 New Scotland Ave., Albany, NY 12208, USA. carlsoa@mail.amc.edu Phymas (swellings, masses, or bulbs) are considered the end-stage of rosacea and mostly affect the nose (rhinophyma), and rarely involve the chin (gnatophyma), the cheek (metophyma), eyelids (blepharophyma), or ears (otophyma). Herein, we report the case of a 57-year-old man who developed unilateral enlargement of his left ear over 2 years. Biopsy revealed changes of rosaceous lymphedema associated with Demodex infestation. Corticosteroid and minocycline therapies resulted in partial reduction of the ear enlargement. Literature review examining for cases of lymphedema (elephantiasis) of the ear revealed that chronic inflammatory disorders (rosacea (most frequent), psoriasis, eczema), bacterial cellulitis (erysipelas), pediculosis, trauma, and primary (congenital) lymphedema can all lead to localized, lymphedematous enlargement of the ear. Depending on the severity, medical treatment directed at the inflammatory condition for mild, diffuse enlargement to surgical debulking for extensive diffuse enlargement or tumor formation can improve the signs and symptoms of otophyma. Decreased immune surveillance secondary to rosaceous lymphedema may explain why Demodex infestation is common in rosacea and support the suspicion that phymatous skin is predisposed to skin cancer development. PMID: 18212550 [PubMed - in process] --------------------------------------------------------------- Ann Plast Surg. 2008 Feb;60(2):228. Lymphedema: a comprehensive review.Shimony A, Tidhar D. PMID: 18216521 [PubMed - in process ----------------------------------------------------------------- Int J Dermatol. 2008 Feb;47(2):174-7. Cutaneous diffuse large B-cell lymphoma of the leg associated with chronic lymphedema.González-Vela MC, González-López MA, Val-Bernal JF, Fernández-Llaca H. Department of Anatomical Pathology, Marqués de Valdecilla University Hospital, Medical Faculty, University of Cantabria, Santander, Spain. Development of malignant tumors is a rare but well known complication in chronic lymphedema (CL). We report herein a cutaneous diffuse large B-cell lymphoma of the leg associated with CL. An 89-year- old man presented with multiple cutaneous lesions on his right limb that showed a CL. Dermatological examination disclosed multiple violaceous, firm, slightly infiltrated nodules on the anterior aspect of the leg and the dorsum and sole of the foot. A biopsy of one nodule of the leg disclosed a diffuse large B-cell lymphoma, type of the legs. There was no evidence of lymphadenopathy on computed tomography (CT) scans of the chest, abdomen, and pelvis. A bone marrow aspiration and biopsy showed normal results. The patient was treated with local radiotherapy at a dose of 40 Gy, obtaining a highly significant, almost complete, clinical remission. A literature search identified 11 additional cases of primary cutaneous lymphoma associated with CL. An inadequate lymphatic drainage may make the lymphedematous region an immunologically vulnerable area, predisposing to neoplasia. PMID: 18211492 [PubMed - in process] -------------------------------------------------------------------- Int J Dermatol. 2008 Feb;47(2):154-9. Cutaneous manifestations of chikungunya fever: observations made during a recent outbreak in south India.Inamadar AC, Palit A, Sampagavi VV, Raghunath S, Deshmukh NS. Department of Dermatology, Venereology and Leprosy, BLDEA's SBMP Medical College, Hospital and Research Center, Bijapur, Karnataka, India. aruninamadar@rediffmail.com BACKGROUND; Chikungunya fever is an Aedes mosquito-borne Arbo viral illness with significant morbidity. METHODS: In a recent outbreak of the disease in south India, the dermatologic manifestations of 145 patients attending a tertiary care hospital were recorded. RESULTS: All age groups were affected, including newborns. Some of the cutaneous features were observed during the acute stage of the illness, and others during convalescence or thereafter. Pigmentary changes were found to be the most common cutaneous finding (42%), followed by maculopapular eruption (33%) and intertriginous aphthous-like ulcers (21.37%). Lesions with significant morbidity were generalized vesiculobullous eruptions (2.75%), found only in infants, lymphedema, and intertriginous aphthous-like ulcers. Exacerbation of existing dermatoses, such as psoriasis, and unmasking of undiagnosed Hansen's disease were observed. A perivascular lymphocytic infiltrate was a consistent histopathologic finding in all types of skin lesions. All patients responded well to symptomatic, conservative treatment. CONCLUSIONS: The cutaneous findings hitherto not reported may be the result of the African genotype of the virus detected during this outbreak in India. PMID: 18211486 [PubMed - in process] ------------------------------------------------------------------------ Plast Reconstr Surg. 2008 Feb;121(2):521-8. Learning from a lymphedema clinic: an algorithm for the management of localized swelling.Garfein ES, Borud LJ, Warren AG, Slavin SA. Boston, Mass. From the Harvard Plastic Surgery Program, Harvard Medical School, and the Division of Plastic Surgery, Beth Israel Deaconess Medical Center. BACKGROUND:: Lymphedema is a chronic disease causing significant morbidity for affected patients. It can be difficult to diagnose, and patients are often frustrated by multiple referrals and inadequate therapies. Centralized, comprehensive care for the patient presenting with lymphedema or other causes of localized swelling allows for appropriate evaluation and provides improved management and treatment. METHODS:: A 4-year review of the first 100 patients seen at the Beth Israel Deaconess Medical Center Lymphedema Clinic was performed. On the basis of the clinical experience from these patients, an algorithm for diagnosing and managing patients with localized swelling was developed. RESULTS:: The mean age of the patients was 50 years, and 81 percent of the patients were women. On average, patients had experienced their symptoms for 11.6 years (range, 3 months to 60 years). Lymphoscintigraphy was performed on 43 patients, 81 percent of whom showed lymphatic obstruction or dysfunction. In total, 75 percent of patients were diagnosed with lymphedema based on clinical presentation or additional testing. Fourteen of these patients underwent subsequent excisional procedures, whereas the rest were managed conservatively with compression garments. CONCLUSIONS:: Patients presenting with swollen extremities can frequently be diagnosed through history and physical examination alone, but many patients require more extensive diagnostic workup. An algorithm for the management of these patients can facilitate evaluation and treatment. PMID: 18300971 [PubMed - in process] ---------------------------------------------------------------------------- Prenat Diagn. 2008 Feb;28(2):167. Perinatal diagnosis of a lymphoedema-distichiasis syndrome.Brice G. St Georges University of London, Clinical Genetics, UK for the Lymphoedema Research Consortium. PMID: 18236429 [PubMed - in process ------------------------------------------------------------------------------ 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, Chaabène 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. 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] 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. 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] ----------------------------------------------------------------------------------------------------- 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] -------------------------------------------------------------------------------------------- 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] -------------------------------------------------------------------------------------------- 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. 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] -------------------------------------------------------------------------------------------- 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. 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] ------------------------------------------------------------------------------------------ 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] ------------------------------------------------------------------------------------------------ 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] ------------------------------------------------------------------------------------------------- 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] ------------------------------------------------------------------------------------- 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] ----------------------------------------------------------------------------------------------- J Eur Acad Dermatol Venereol. 2008 Apr;22(4):409-16. Re-emergence of lymphogranuloma venereum. Kapoor S. 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] -------------------------------------------------------------------------------------------- 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 --------------------------------------------------------------------------------------- Br J Nurs. 2008 Apr 10-23;17(7):428, 430-3.Links Toe bandaging for lymphoedema and venous ulceration.McCann M. St Georges Hospital, London. Lymphoedema and chronic venous insufficiency with venous leg ulceration have long been viewed as distinctly separate entities. This article explores how toe bandaging, a skill used routinely in lymphoedema practice, might benefit people being bandaged to treat venous leg ulcers. A small research study identified that 12 out of 124 people receiving high compression bandaging for venous leg ulcers without toe bandaging developed toe ulceration during a 2-year period. A second study has found no episodes of toe ulceration in patients receiving toe bandaging as part of their care. Unfortunately, there was significant heterogeneity between the two trials in terms of the client group, duration of bandaging and bandaging techniques, meaning that firm conclusions could not be extrapolated. A brief discussion of the pathophysiology and bandaging techniques used for lymphoedema and venous leg ulcers is used in this article to try and explore the rationale behind whether to bandage the toes or not, and to try and help practitioners decide whether toe bandaging should become part of all compression bandaging regimens. PMID: 18642684 [PubMed - indexed for MEDLINE] -------------------------------------------------------------------------------------------- : Ann Dermatol Venereol. 2008 Jun-Jul;135(6-7):488-91. Epub 2008 Apr 14. [Cutaneous angiosarcoma of the leg without lymphoedema][Article in French] Le Corre Y, Avenel-Audran M, Croué A, Steff M, Verret JL. Service de dermatologie, faculté de médecine, université d'Angers, CHU d'Angers, 4, rue Larrey, 49933 Angers cedex 09, France. BACKGROUND: Cutaneous angiosarcoma is a rare aggressive vascular neoplasm with a poor prognosis, seen chiefly in elderly subjects and usually on the scalp or face. The present case is original because of its localization on the leg without any chronic lymphoedema and because of the long survival period. The treatment modalities are discussed. CASE REPORT: An 87-year-old woman presented with a rapidly growing large deep-purple ulcerated tumour on the anterior aspect of the leg. In addition, two nodules with a similar aspect appeared on the outer surface of the foot. Histological examination showed vascular channels lined with atypical cells consistent with a diagnosis of angiosarcoma. Computed tomography revealed no metastases. Amputation was performed at the thigh and there was no recurrence 30 months later. DISCUSSION: The leg is a rare site of cutaneous angiosarcoma. Treatment usually consists of surgical excision with wide margins followed by radiotherapy, but in some cases amputation is unavoidable. PMID: 18598799 [PubMed - in process] : Ann Dermatol Venereol. 2008 Jun-Jul;135(6-7):488-91. Epub 2008 Apr 14. [Cutaneous angiosarcoma of the leg without lymphoedema][Article in French] Le Corre Y, Avenel-Audran M, Croué A, Steff M, Verret JL. Service de dermatologie, faculté de médecine, université d'Angers, CHU d'Angers, 4, rue Larrey, 49933 Angers cedex 09, France. BACKGROUND: Cutaneous angiosarcoma is a rare aggressive vascular neoplasm with a poor prognosis, seen chiefly in elderly subjects and usually on the scalp or face. The present case is original because of its localization on the leg without any chronic lymphoedema and because of the long survival period. The treatment modalities are discussed. CASE REPORT: An 87-year-old woman presented with a rapidly growing large deep-purple ulcerated tumour on the anterior aspect of the leg. In addition, two nodules with a similar aspect appeared on the outer surface of the foot. Histological examination showed vascular channels lined with atypical cells consistent with a diagnosis of angiosarcoma. Computed tomography revealed no metastases. Amputation was performed at the thigh and there was no recurrence 30 months later. DISCUSSION: The leg is a rare site of cutaneous angiosarcoma. Treatment usually consists of surgical excision with wide margins followed by radiotherapy, but in some cases amputation is unavoidable. PMID: 18598799 [PubMed - in process] -------------------------------------------------------------------------- 1: Br J Community Nurs. 2008 Apr;13(4):S25-6, S28-32.Links Managing chronic oedema: a collaborative community approach.Lewis M, Morgan K. Singleton Hospital, Swansea Chronic oedema affects over 100 000 people in the UK and is regularly treated by different health care professionals, most commonly community nurses. The effect of chronic oedema on patients can be both physical and emotional and is a huge financial burden on the NHS. Collaborative working between lymphoedema services and community nurses is outlined in this article, highlighting potential benefits to patient care and substantial cost savings. Modified lymphoedema management strategies to treat chronic oedema effectively are identified with the emphasis on joint packages of care and patient goal setting. The role of health care professionals working collaboratively and empowering patients are also discussed in a case study. PMID: 18595309 [PubMed - indexed for MEDLINE] ------- : Br J Community Nurs. 2008 Apr;13(4):S18, S20-4.Links A community nursing guide: multilayer lymphoedema bandaging.Hopkins A. Gloucestershire Hospitals NHS Foundation Trust. Multi-layer lymphoedema bandaging (MLLB) has been clinically proven to reduce oedema, improve skin complications and reduce infection. MLLB differs from four layer bandaging traditionally used to treat leg ulceration. This article identifies some of the differences between the two methods, suggests when best to use MLLB, describes an MLLB technique and considers the implications for training. PMID: 18595308 [PubMed - indexed for MEDLINE] ---------------------------------------------------------- 1: Br J Community Nurs. 2008 Apr;13(4):S11-2, S14, S16-7.Links Survey of Doppler use in lymphoedema practitioners in the UK.Todd M, Welsh J, Key M, Rice M, Adam J. Specialist Lymphoedema Service Glasgow. mar Lymphoedema practitioners anecdotally don't use Doppler in the vascular assessment of their patients prior to the application of compression. The belief is that the results are inaccurate in the presence of oedema. The objective of this article is to gather information about the use of Doppler by lymphoedema specialists in the vascular assessment of lymphoedema patients in the UK. A questionnaire on the use of Doppler in lymphoedema patients was distributed to 250 delegates attending the British Lymphology Society Conference in Glasgow in Ocotber 2005. There appears to be no consensus in the method of vascular assessment of lymphoedema patients. More research is needed to ascertain the accuracy of Doppler in the assessment of lymphoedema patients. Guidelines are also required in the vascular assessment of lymphoedema patients based on scientifically valid evidence. PMID: 18595307 [PubMed - indexed for MEDLINE] --------------------------------------------------------- Br J Community Nurs. 2008 Apr;13(4):S4, S6, S8-10.Links Pharmacological treatment for chronic oedema.Keeley V. Derby Hospitals NHS Foundation Trust. Chronic oedema is mainly treated by physical methods (compression, lymphatic drainage, massage and exercise), with drugs not having a major role to play. However, antibiotics are essential in the management of cellulitis, a common and important complication of chronic oedema. Diuretics and cortico-steroids may be appropriate in some types of oedema such as that associated with advanced cancer. Analgesics may be helpful in managing pain, particularly in the short term e.g. pain from cellulitis, although long-term use may also be appropriate, e.g. in cancer pain. Benzopyrones are not routinely used in the management of lymphoedema in the UK. PMID: 18595306 [PubMed - indexed for MEDLINE] ------------------------------------------------------------------ Br J Community Nurs. 2008 Apr;13(4):S3.Links Chronic oedema. Recognizing your skills.Billingham R. PMID: 18595305 [PubMed - indexed for MEDLINE --------------------------------------------------------------- Parasitol Int. 2008 Sep;57(3):390-5. Epub 2008 Apr 12. Links Distribution of filarial elephantiasis and hydrocele in Matara district, Sri Lanka, as reported by local leaders, and an immunological survey in areas with relatively high clinical rates.Weerasooriya MV, Isogai Y, Itoh M, Yahathugoda TC, Vidanapathirana KK, Mudalige MP, Kimura E. Filariasis Research Training and Service Unit, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka. To eliminate lymphatic filariasis by means of mass drug administration, it is essential to have reliable data on the disease distribution and prevalence in targeted areas. In Matara district, Sri Lanka, self- administered questionnaires were mailed to 2105 local leaders questioning the presence and the numbers of elephantiasis and hydrocele cases. The information provided by them revealed that elephantiasis was clearly aggregated in the southern part of the district along the coast, while hydrocele was distributed rather evenly in the whole district, including Deniyaya region where no endemic filariasis had been known. To confirm active transmission of filariasis in Deniyaya, Wuchereria bancrofti antigen and filaria- specific urinary IgG4 antibody were measured with 2436 subjects. The positive rates for antigen and antibody were 0.6% and 4.3%, respectively. The titer analysis of IgG4 according to age revealed that the youngest IgG4 positive was 3 years old, and that in 10 years old or less, there were 16 positives out of 607 children examined (2.6%). It was concluded that filarial transmission at a low level was going on in the region. PMID: 18508407 [PubMed - indexed for MEDLINE] ---------------------------------------------------------------------- http://www.ncbi.nlm.nih.gov/pubmed/18481770?ordinalpos=9&itool=EntrezSystem2.PEntrez.Pubmed. Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum Rev Infirm. 2008 Apr;(139):21-2.Links [How the specialties nurse team deals with treatment of lymphedema][Article in French] Devred M. Unité de lymphologie, Hôpital Cognacq-Jay, Paris. PMID: 18481770 [PubMed - indexed for MEDLINE] ----------------------------------------------------------------------- J Reprod Med. 2008 Apr;53(4):299-301.Links Recurrent vulvar lymphangitis cured with vulvectomy in a cervical carcinoma patient: a case report.Micha JP, Goldstein BH, Rettenmaier MA, Tinnerman-Minailo EJ, Brown JV 3rd, McClellan SN, Bock BV. Gynecologic Oncology Associates, Hoag Cancer Center, Newport Beach, California 92663, USA. BACKGROUND: Recurrent vulvar lymphangitis secondary to pelvic lymphadenectomy and radiation therapy can be a vexing clinical dilemma. CASE: A 55-year-old woman was initially treated with radical hysterectomy and 1 postoperative radiotherapy for cervical carcinoma in 1984. In 1987 she developed persistent vulvar, leg, and ankle edema; chronic vulvar pain; and recurrent vulvar cellulitis, which were ultimately attributed to group B Streptococcus. Despite long-term antibiotic therapy and compression stockings, the cellulitis was intractable. In June 2006 the patient underwent a bilateral simple vulvectomy with preservation of the clitoris and insertion of bilateral subcutaneous Jackson-Pratt drains. Her postoperative culture results revealed normal vaginal flora. CONCLUSION: The patient's wounds healed very well, and she has had no further episodes of vulvitis or lymphangitis. The management of recurrent infections involving lymphedema can be difficult and cause complicated clinical issues. PMID: 18472655 [PubMed - indexed for MEDLINE] --------------------------------------------------------------------------- Vascul Pharmacol. 2008 Apr-Jun;48(4-6):150-6. Epub 2008 Mar 10. Links Effect of vascular endothelial growth factor C (VEGF-C) gene transfer in rat model of secondary lymphedema.Liu Y, Fang Y, Dong P, Gao J, Liu R, Hhahbaz M , Bi Y, Ding Z, Tian H, Liu Z. Department of Anatomy, Shandong University School of Medicine, Jinan, 250012, China. Secondary lymphedema has been clinically well described, but a cure is still lacking. Although there have been previous investigations using plasmid DNA for gene therapy, few have focused on the use for the treatment of lymphedema. Therefore, we investigated the effects of VEGF-C gene transfer for the treatment of lymphedema using our plasmid pcDNA3.1-VEGF-C. We produced a surgical model of secondary lymphedema in the rat hindlimb and treated with local intradermal VEGF-C transfection to investigate the efficacy of gene transfer. Magnetic resonance imaging (MRI) (P<0.05), B ultrasound (P<0.05), and water displacement volumetry (P<0.05) demonstrated a reduction of lymphedema in therapy group as compared to controls. Histological and immunofluorescent studies demonstrated numerous newly formed lymphatic vessels in therapy group. Our results indicate that VEGF-C gene therapy has produced new lymphatic vessels which may have improved functional lymphatic drainage to reduce lymphedema volume in our model. PMID: 18455964 [PubMed - in process] ---------------------------------------------------------------------------- Breast. 2008 Apr 29. [Epub ahead of print] Links Postmastectomy neuropathic pain: Results of microsurgical lymph nodes transplantation.Becker C, Pham DN, Assouad J, Badia A, Foucault C, Riquet M. Service de Chirurgie Thoracique, Hôpital Européen Georges Pompidou, 20-40 rue Leblanc, 75015 Paris Cedex, France. Postmastectomy chronic pain may be divided into widespread and regional pain. Almost half patients with regional pain, which is more likely related to neuropathic phenomena, do not benefit any pain relief from medication. Our purpose was to report results on pain relief obtained by axillary lymph nodes autotransplantation. METHODS: Six patients presented with chronic regional neuropathic pains and upper limb lymphedema after breast cancer surgery and radiation therapy. Despite medication, pain was intolerable and daily activity dramatically reduced. Lymph nodes were harvested in the femoral region, transferred to the axillary region and transplanted by microsurgical procedures. RESULTS: Lymphedema resolved in 5 out of 6 patients. Pain was relieved in all, permitting return to work and daily activity; analgesic medication was discontinued. CONCLUSION: This procedure proved efficient and may be advocated in case of neuropathic pain when discussing lymphedema management. PMID: 18450444 [PubMed - as supplied by publisher] -------------------------------------------------------------------------------- Ir J Med Sci. 2008 Apr 22. [Epub ahead of print] Links Surgical debulking in a case of chronic lymphoedema.Campbell W, Harkin DW. Regional Vascular Surgery Unit, Royal Victoria Hospital, Belfast, BT12 6BA, Northern Ireland, UK, Lymphoedema can present with an array of distressing symptoms, which can pose significant management dilemmas. First-line treatment involves established therapies including elevation, manual drainage and compression hosiery. However, failure of these medical strategies can occasionally necessitate surgical intervention to alleviate symptoms. This case highlights the role of surgical debulking in the management of an intractable case of lower limb lymphoedema with symptoms so severe that the patient requested amputation of her left lower extremity. This report also describes other surgical modalities in the management of this debilitating condition. PMID: 18427877 [PubMed - as supplied by publisher] --------------------------------------------------------------------------------------- Cochrane Database Syst Rev. 2008 Apr 16;(2):CD001899. Update of: Cochrane Database Syst Rev. 2001;(4):CD001899. Intermittent pneumatic compression for treating venous leg ulcers.Nelson EA, Mani R, Vowden K. University of Leeds, School of Healthcare, Baines Wing, Leeds, UK, LS2 9UT. e.a.nelson@leeds.ac.uk BACKGROUND: Intermittent pneumatic compression (IPC) is a mechanical method of delivering compression to swollen limbs that can be used to treat venous leg ulcers and limb swelling due to lymphoedema. This review analyses the evidence for the effectiveness of IPC as a treatment for venous leg ulcers. OBJECTIVES: To determine whether IPC increases the healing of venous leg ulcers. To determine the effects of IPC on health related quality of life of venous leg ulcer patients. SEARCH STRATEGY: We searched the Cochrane Wounds Group Specialised Register (December 2007); the Cochrane Central Register of Controlled Trials (CENTRAL) - The Cochrane Library Issue 4, 2007; Ovid MEDLINE - 2006 to November Week 2 2007; Ovid EMBASE - 2006 to 2007 Week 49 and Ovid CINAHL - 2006 to December Week 1 2007. SELECTION CRITERIA: Randomised controlled studies either comparing IPC with control (sham IPC or no IPC) or comparisons between IPC treatment regimens, in venous ulcer management were included. DATA COLLECTION AND ANALYSIS: Data extraction and assessment of study quality were undertaken by one author and checked by a second. MAIN RESULTS: Seven randomised controlled trials (including 367 people in total) were identified. Only one trial reported both allocation concealment and blinded outcome assessment.In one trial (80 people) more ulcers healed with IPC than with dressings (62% vs 28%; p=0.002). Four trials compared IPC with compression against compression alone. The first of these trials (45 people) found increased ulcer healing with IPC plus compression than with compression alone (relative risk for healing 11.4, 95% Confidence Interval 1.6 to 82). The remaining three trials (122 people) found no evidence of a benefit for IPC plus compression compared with compression alone. One small trial (16 people) found no difference between IPC (without additional compression) and compression bandages alone. One trial compared different ways of delivering IPC (104 people) and found that rapid IPC healed more ulcers than slow IPC (86% vs 61%; log rank p=0.003). AUTHORS' CONCLUSIONS: IPC may increase healing compared with no compression, but it is not clear whether it increases healing when added to treatment with bandages, or if it can be used instead of compression bandages. Rapid IPC was better than slow IPC in one trial. Further trials are required to determine whether IPC increases the healing of venous leg ulcers when used in modern practice where compression therapy is widely used. PMID: 18425876 [PubMed - indexed for MEDLINE] ---------------------------------------------------------------------------------------- Ann Dermatol Venereol. 2008 Apr;135(4):299-303. Epub 2008 Mar 20. Links [Intravascular B-cell lymphoma with febrile inflammatory lymphoedema of the lower limbs and lower back][Article in French] Pallure V, Dandurand M, Stoebner PE, Habib F, Colonna G, Meunier L. Service de dermatologie, groupe hospitalo-universitaire Carémeau, rue du Professeur-Robert-Debré, 30900 Nîmes, France. BACKGROUND: Intravascular lymphomas are diffuse large-cell lymphomas belonging to a group of high-grade non-Hodgkin's lymphomas and are generally of phenotype B. They are rare and carry a severe prognosis. Clinical polymorphism is dominated by neurological and cutaneous involvement. PATIENTS AND METHODS: We report the case of an 80-year-old woman with cutaneous intravascular B-cell lymphoma as revealed by an isolated episode of febrile bilateral inflammatory lymphoedema. Following combined chemotherapy with rituximab and mini-CHOP (cyclophosphamide, adriamycin, oncovin and prednisone), complete remission was obtained rapidly, with no relapse at two years. DISCUSSION: Diagnosis of these tumours is rendered difficult by the clinical polymorphism and multifocal nature of lymphocytic proliferations. In the present case, diagnosis was based on histology results since presentation of the disease in the form of bilateral inflammatory oedema of the lower limbs is not sufficient to establish lymphoma. Combined rituximab and polychemotherapy comprising a CHOP regimen appears to yield the best results. PMID: 18420078 [PubMed - indexed for MEDLINE] -------------------------------------------------------------------------------------------------- Mol Cell Biol. 2008 Jun;28(12):4026-39. Epub 2008 Apr 14. Links Emilin1 deficiency causes structural and functional defects of lymphatic vasculature.Danussi C, Spessotto P, Petrucco A, Wassermann B, Sabatelli P, Montesi M, Doliana R, Bressan GM, Colombatti A. Division of Experimental Oncology 2, Department of Molecular Oncology and Translational Research, CRO-IRCCS, Aviano, Pordenone, Italy. Lymphatic-vasculature function critically depends on extracellular matrix (ECM) and on its connections with lymphatic endothelial cells (LECs). However, the composition and the architecture of ECM have not been fully taken into consideration in studying the biology and the pathology of the lymphatic system. EMILIN1, an elastic microfibril-associated protein, is highly expressed by LECs in vitro and colocalizes with lymphatic vessels in several mouse tissues. A comparative study between WT and Emilin1-/- mice highlighted the fact that Emilin1 deficiency in both CD1 and C57BL/6 backgrounds results in hyperplasia, enlargement, and frequently an irregular pattern of superficial and visceral lymphatic vessels and in a significant reduction of anchoring filaments. Emilin1-deficient mice also develop larger lymphangiomas than WT mice. Lymphatic vascular morphological alterations are accompanied by functional defects, such as mild lymphedema, a highly significant drop in lymph drainage, and enhanced lymph leakage. Our findings demonstrate that EMILIN1 is involved in the regulation of the growth and in the maintenance of the integrity of lymphatic vessels, a fundamental requirement for efficient function. The phenotype displayed by Emilin1(-/-) mice is the first abnormal lymphatic phenotype associated with the deficiency of an ECM protein and identifies EMILIN1 as a novel local regulator of lymphangiogenesis. PMID: 18411305 [PubMed - indexed for MEDLINE] PMCID: PMC2423131 [Available on 10/01/08] ------------------------------------------------------------------------------------------------ .Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum Clin Transl Oncol. 2008 Apr;10(4):213-8.Links Implementation of a comprehensive cancer plan. A health planning experience.Expósito Hernández J, Domínguez Nogueira C, Escalera de Andrés C. Plan Integral de Oncología, Unidad de investigación, H.U. Virgen de las Nieves, Granada, Spain. jose. Here we describe the working method used to implement an Integrated Cancer Health Plan in Andalusia (Spain) and to set out some of the lines of work for improving quality of care and health network planning. Four main initial considerations were made: (1) work must be centred on patients and respect for their autonomy; (2) cancer requires action at every healthcare level; (3) integration of expert professionals is to be encouraged; and (4) relevant information and data should be systematically used for planning. Two operative approaches were also established: structured participation and evidence- based healthcare. This methodology was used in various planning programmes, largely in relation to healthcare resources. In this article, as examples, we describe the development of two types of programmes: one for radiotherapy equipment and another for the management of lymphoedema in breast cancer patients. Analysis of results obtained against cancer is always controversial. It is necessary to review the healthcare structure used in terms of effectiveness and excellence. Comprehensive or integrated health plans are a useful model for a wide-ranging and multi-level approach to cancer. The structured and real participation of experts and an evidence- based healthcare strategy proved very useful in this public health planning experience. PMID: 18411194 [PubMed - indexed for MEDLINE] ------------------------------------------------------------------------------------------------- http://www.ncbi.nlm.nih.gov/pubmed/18403655?ordinalpos=18&itool=EntrezSystem2.PEntrez.Pubmed. Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum Chest. 2008 Aug;134(2):375-81. Epub 2008 Apr 10. Links Yellow nail syndrome: analysis of 41 consecutive patients.Maldonado F, Tazelaar HD, Wang CW, Ryu JH. Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, USA. BACKGROUND: Yellow nail syndrome (YNS) is a rare condition defined by the presence of yellow nails associated with lymphedema and/or chronic respiratory manifestations. Several aspects of this disorder remain poorly defined. METHODS: We sought to clarify the clinical features and course associated with YNS by analyzing 41 consecutive cases evaluated at a tertiary referral medical center. RESULTS: There were 20 men and 21 women; median age at diagnosis was 61 years (range, 18 to 82 years). None had a family history of YNS. All but one patient had chronic respiratory manifestations that included pleural effusions (46%), bronchiectasis (44%), chronic sinusitis (41%), and recurrent pneumonias (22%); 26 patients (63%) had lymphedema. Treatment included rotating antibiotic therapy for bronchiectasis, thoracenteses, oral vitamin E, and corticosteroid therapy. Eight patients underwent surgical management of recurrent pleural effusions including pleurodesis and decortication; two additional patients underwent pleurodesis via tube thoracostomy. The yellow nails improved or resolved in 14 of 25 patients (56%) for whom relevant data were available. Median survival of this cohort using the Kaplan- Meier method was 132 months, significantly lower than (p = 0.01) the control population. Among those still alive (20 patients), the disease appeared stable. CONCLUSIONS: In most cases, YNS is an acquired disorder and associated respiratory manifestations are generally manageable with a regimen of medical and surgical treatments. Yellow nails improve in about one half of patients, often without specific therapy. PMID: 18403655 [PubMed - in process] --------------------------------------------------------------------------------------------- http://www.ncbi.nlm.nih.gov/pubmed/18398585?ordinalpos=19&itool=EntrezSystem2.PEntrez.Pubmed. Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum Strahlenther Onkol. 2008 Apr;184(4):206-11. Links Lymph edema of the lower extremities after lymphadenectomy and radiotherapy for cervical cancer. Füller J, Guderian D, Köhler C, Schneider A, Wendt TG. Department of Radiooncology, University Hospital, Friedrich Schiller University of Jena, Germany. Juergen.Fueller@med.uni-jena.de PURPOSE: To assess the incidence of clinical lymph edema after lymphadenectomy and postoperative radiotherapy (RT). PATIENTS AND METHODS: From 1994-2002 192 patients with risk factors for recurrence received radiotherapy with FIGO I (58.8%), II (35.4%), III (4.2%) or IV (1.6%). RT consisted of teletherapy (10.4%), brachytherapy of the vaginal vault (20.8%) or a combination of both (68.8%). Additional chemotherapy was given in 69 patients (35.9%). Surgery comprised laparoscopically assisted radical vaginal hysterectomy (LARVH) (35.4%), radical abdominal hysterectomy (RAH) (48.4%), simple hysterectomy (HE) (11.5%) or exenteration (4.7%). RESULTS: 73 patients had lymph node metastases, 119 had negative lymph nodes. In patients with LARVH 6-74 (median 30) lymph nodes were removed, with RAH 3-70 (median 21 lymph nodes), and after HE or exenteration 5-50 (median 13 lymph nodes). 90 patients had 25 or less lymph nodes removed, 83 patients more than 25 lymph nodes removed. Prognostic factors, such as age, FIGO stages, histologic grading and type of histology were well balanced in these cohorts. 45 (23.4%) of all patients developed clinically relevant lymph edema of the lower limb with a median latency of 11 (1-121) months. When 25 or less lymph nodes were removed 17.8% of patients developed leg edema, when more than 25 lymph nodes were removed 32.5% of patients were diagnosed with lymph edema (p = 0.025). Radiotherapy and chemotherapy had no influence on the incidence of leg edema. Overall survival at 5 (10) years was independent of number of lymph nodes removed. CONCLUSION: The data suggest increasing rates of leg edema with increasing number of lymph nodes dissected independent of the type of radiotherapy and chemotherapy performed. The lymph node sampling policy should be planned carefully in respect to minimize the risk of leg lymph edema. PMID: 18398585 [PubMed - indexed for MEDLINE] -------------------------------------------------------------------------------------- http://www.ncbi.nlm.nih.gov/pubmed/18389432?ordinalpos=20&itool=EntrezSystem2.PEntrez.Pubmed. Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum Health Care Women Int. 2008 Apr;29(4):349-65 "Can it be that god does not remember me": a qualitative study on the psychological distress, suffering, and coping of Dominican women with chronic filarial lymphedema and elephantiasis of the leg.Person B, Addiss D, Bartholomew LK, Meijer C, Pou V, Gonzálvez G, Borne BV. Centers for Disease Control and Prevention, National Center for Preparedness, Detection, and Control of Infectious Diseases, Atlanta, Georgia 30333, USA. BEP2@cdc.gov The psychological states of Dominican women with chronic lymphedema and elephantiasis of the leg and the coping strategies they used to ameliorate the negative psychological effects of this condition were explored using modified precepts of grounded theory method. Qualitative data were gathered through in- depth interviewing and focus group discussions held in the Dominican Republic. Thematic results found that compounding their physical disfigurement, functional limitations, and social losses were feelings of depression, embarrassment, social isolation, and despair. Adaptive problem solving and emotion- focused coping strategies that emerged during analysis also are discussed. It is recommended that management of psychological distress should be a significant component of lymphedema management programs in developing countries. PMID: 18389432 [PubMed - indexed for MEDLINE] ------------------------------------------------------------------------------- http://www.ncbi.nlm.nih.gov/pubmed/18385349?ordinalpos=21&itool=EntrezSystem2.PEntrez.Pubmed. Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum Am J Trop Med Hyg. 2008 Apr;78(4):560-3. Links Seroconversion to filarial antigens in Australian defence force personnel in Timor-Leste.Frances SP, Baade LM, Kubofcik J, Nutman TB, Melrose WD, McCarthy JS, Nissen MD. Australian Army Malaria Institute, Gallipoli Barracks, Enoggera, Queensland, Australia. steve. frances@defence.gov.au To investigate whether Australian soldiers were exposed to filarial parasites that cause lymphatic filariasis during a 6-month deployment to Timor-Leste, antifilarial antibody levels were measured in 907 soldiers using an enzyme linked immunosorbent assay (ELISA). Initial testing using Dirofilaria immitis antigen demonstrated that 49 of 907 (5.4%) soldiers developed antifilarial antibodies of the IgG1 subclass after deployment, whereas 1 of 944 (0.1%) seroconverted to the IgG4 subclass. When a sub sample of 88 D. immitis-reactive sera was subject to testing with an antifilarial antibody test using Brugia malayi antigen, 46 had elevated IgG antibodies, whereas 5 had elevated antibodies of the IgG4 subclass. A total of 24 soldiers seroconverted to B. malayi, as measured by parasite-specific IgG, whereas 1 seroconverted to IgG4. The relatively low number of seroconversions indicates a low but measurable risk of exposure to human filarial parasites among Australian soldiers deployed to Timor-Leste. However, to reduce the risk of exposure to these parasites, soldiers deploying to endemic areas should practice strict adherence to personal protective measures against mosquito bites. PMID: 18385349 [PubMed - indexed for MEDLINE] ---------------------------------------------------------------------------------- http://www.ncbi.nlm.nih.gov/pubmed/18384209?ordinalpos=22&itool=EntrezSystem2.PEntrez.Pubmed. Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum Arch Pathol Lab Med. 2008 Apr;132(4):579-86. Links Pseudosarcomas of soft tissue.Rosenberg AE. Department of Pathology, James Homer Wright Laboratories, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA. arosenberg@partners.org One of the most common and important pitfalls in soft tissue pathology are the so-called pseudosarcomas. These lesions are nonneoplastic; however, their rapid growth, hypercellularity, cytologic atypia, and mitotic activity makes them prone to be misinterpreted as sarcoma. The most common of these lesions are fibroblastic/myofibroblastic and matrix-forming proliferations, including nodular fasciitis, proliferative fasciitis and myositis, ischemic fasciitis, massive localized edema, myositis ossificans, and bizarre parosteal osteochondromatous proliferation and related entities. Most of these lesions rarely recur following simple excision; therefore, their accurate recognition helps prevent excessive therapy. PMID: 18384209 [PubMed - indexed for MEDLINE] ----------------------------------------------------------------------------------- http://www.ncbi.nlm.nih.gov/pubmed/18376345?ordinalpos=23&itool=EntrezSystem2.PEntrez.Pubmed. Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum : Med Sci Monit. 2008 Apr;14(4):CR183-9. Links Feasibility of routine lymphadenectomy in clinical stage-I endometrial cancer.Han SS, Cho JY, Park IA, Park SK, Jeon YT, Kim JW, Park NH, Kang SB, Lee HP, Song YS. Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Jongno-Gu, Seoul, Korea. BACKGROUND: To determine the accuracy of several preoperative tests in predicting lymph node (LN) metastases and the feasibility of doing a routine lymphadenectomy in clinical stage-I endometrial cancer. MATERIAL/METHODS: We reviewed 132 patients with clinical stage-I endometrial cancer. The preoperative tests used to predict LN metastases were serum CA-125 level, histologic type and grade, LN status assessed by pelvic magnetic resonance image (MRI) or computed tomography (CT), and depth of myometrial invasion assessed only by pelvic MRI. The cutoff value of the serum CA-125 level was determined using receiver operating characteristic curves. Multivariate logistic regression analyses were used to determine which tests are good predictors of LN metastases. RESULTS: Of 132 patients, 13 (9.8%) had LN metastases. On univariate logistic regression analysis, a high CA-125 level and preoperative LN evaluation by pelvic MRI or CT were significant predictors for LN metastases (OR=17.41, 95% CI: 4.36-69.56 and OR=14.30, 95% CI: 4.02-50.63, respectively). However, on multivariate logistic regression analysis adjusted for age and all preoperative tests, a high CA-125 level was the most significant predictor (OR=13.73, 95% CI: 2.03-92.73). Among the 97 patients with no significant predictor of LN metastases, pelvic LN metastases were observed in 3 patients (3.1%) and para-aortic LN metastases were observed in 1 patient (1.1%). Surgical complications were mild (lymphocele, n=9; lymphedema, n=2; wound problem, n=2). CONCLUSIONS: Considering the importance of LN metastases as an indicator of prognosis, and the relatively low surgical risk of lymphadenectomy, clinicians should cautiously consider routine lymphadenectomy in patients with clinical stage-I endometrial cancer. PMID: 18376345 [PubMed - indexed for MEDLINE] --------------------------------------------------------------------------------------- http://www.ncbi.nlm.nih.gov/pubmed/18364503?ordinalpos=24&itool=EntrezSystem2.PEntrez.Pubmed. Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum J Natl Cancer Inst. 2008 Apr 2;100(7):449-50. Epub 2008 Mar 25. Links Comment on: J Natl Cancer Inst. 2008 Apr 2;100(7):462-74. Early adoption and disturbing disparities in sentinel node biopsy in breast cancer.Edge SB. PMID: 18364503 [PubMed - indexed for MEDLINE -------------------------------------------------------------------------------------- http://www.ncbi.nlm.nih.gov/pubmed/18363909?ordinalpos=25&itool=EntrezSystem2.PEntrez.Pubmed. Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum J Eur Acad Dermatol Venereol. 2008 Apr;22(4):409-16. Links 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 - indexed for MEDLINE] ---------------------------------------------------------------------------------------- http://www.ncbi.nlm.nih.gov/pubmed/18346521?ordinalpos=26&itool=EntrezSystem2.PEntrez.Pubmed. Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum J Pediatr. 2008 Apr;152(4):587-9, 589.e1-3. Links Lymphatic dysplasias in newborns and children: the role of lymphoscintigraphy.Bellini C, Boccardo F, Campisi C, Villa G, Taddei G, Traggiai C, Bonioli E. Neonatal Intensive Care Unit, Department of Pediatrics, University of Genoa, G. Gaslini Institute, Genoa, Italy. carlobellini@ospedalegaslini.ge.it We performed lymphoscintigraphy in 15 patients (newborns and children) affected by congenital lymphatic dysplasia. We suggest that lymphoscintigraphy is mandatory in all patients with signs of lymphatic dysplasia, including those with minimal and initial signs of lymphatic impairment, to obtain very early diagnosis and begin treatment. PMID: 18346521 [PubMed - indexed for MEDLINE] ---------------------------------------------------------------------------- http://www.ncbi.nlm.nih.gov/pubmed/18337654?ordinalpos=27&itool=EntrezSystem2.PEntrez.Pubmed. Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum Melanoma Res. 2008 Apr;18(2):161-2. Links Dramatic reduction of chronic lymphoedema of the lower limb with sorafenib therapy.Moncrieff M, Shannon K, Hong A, Hersey P, Thompson J. Sydney Melanoma Unit, North Sydney, New South Wales, Australia. marc@moncrieff.net This paper describes an interesting case report based on a patient who had a dramatic and astounding reduction in her chronic lymphoedema while on sorafenib. PMID: 18337654 [PubMed - indexed for MEDLINE] ---------------------------------------------------------------------------------- http://www.ncbi.nlm.nih.gov/pubmed/18317033?ordinalpos=28&itool=EntrezSystem2.PEntrez.Pubmed. Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum Curr Opin Infect Dis. 2008 Apr;21(2):122-8. Links Management of common bacterial infections of the skin.Bernard P. Department of Dermatology, Robert Debré Hospital, Reims, France. pbernard@chu-reims.fr 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 - indexed for MEDLINE] --------------------------------------------------------------------------------- http://www.ncbi.nlm.nih.gov/pubmed/18255128?ordinalpos=29&itool=EntrezSystem2.PEntrez.Pubmed. Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum Gynecol Oncol. 2008 Apr;109(1):65-70. Epub 2008 Feb 5. Links Isolated sentinel lymph node dissection with conservative management in patients with squamous cell carcinoma of the vulva: a prospective trial.Moore RG, Robison K, Brown AK, DiSilvestro P, Steinhoff M, Noto R, Brard L, Granai CO. Program in Women's Oncology, Women and Infants' Hospital, Brown University, Providence, RI 02905, USA. rmoore@wihri.org OBJECTIVES: Sentinel lymph node (SLN) dissections have a high sensitivity and negative predictive value for the detection of metastatic disease. The objective of this study was to examine the inguinal recurrence rate along with complication rates for patients undergoing inguinal SLN dissection alone for vulvar carcinoma. METHODS: An IRB approved prospective study enrolled patients with biopsy proven squamous cell carcinoma of the vulva. Peritumoral injection of Tc-99 sulfur colloid and methylene blue dye was used to identify SLNs intraoperatively. Patients with SLNs negative for metastatic disease were followed clinically. Patients with metastasis detected in a SLN subsequently underwent a full groin node dissection followed by standard treatment protocols. RESULTS: Thirty-six patients were enrolled onto study with 35 undergoing a SLN dissection. All SNL dissections were successful with a mean of 2 SLN obtained per groin. There were 24 patients with stage I disease, 8 stage II, 3 stage III and 1 stage IV. A total of 56 SLN dissections were performed with 4 patients found to have inguinal metastasis by SLN dissection. There were 31 patients with a total of 46 SLN dissections found to be negative for metastatic disease. The median follow-up has been 29 months (range 8 to 51) with 2 groin recurrences for a groin recurrence rate of 4.3% and a recurrence rate per patient of 6.4%. There have been no reports of groin breakdown, extremity cellulitis or lymphedema. CONCLUSIONS: The recurrence rate for patients undergoing inguinal sentinel node dissection alone is low. These patients did not experience any complications as seen with complete groin node dissections. Sentinel lymph node dissection should be considered as an option for evaluation of inguinal nodes for metastatic disease. PMID: 18255128 [PubMed - indexed for MEDLINE] --------------------------------------------------------------------------------------- http://www.ncbi.nlm.nih.gov/pubmed/18222033?ordinalpos=30&itool=EntrezSystem2.PEntrez.Pubmed. Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum Ultrasound Med Biol. 2008 Apr;34(4):617-29. Epub 2008 Jan 25. Links The spatio-temporal strain response of oedematous and nonoedematous tissue to sustained compression in vivo.Berry GP, Bamber JC, Mortimer PS, Bush NL, Miller NR, Barbone PE. Joint Department of Physics, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK. gearoid.berry@icr.ac.uk Poroelastic theory predicts that compression-induced fluid flow through a medium reveals itself via the spatio-temporal behaviour of the strain field. Such strain behaviour has already been observed in simple poroelastic phantoms using generalised elastographic techniques (Berry et al. 2006a, 2006b). The aim of this current study was to investigate the extent to which these techniques could be applied in vivo to image and interpret the compression-induced time-dependent local strain response in soft tissue. Tissue on both arms of six patients presenting with unilateral lymphoedema was subjected to a sustained compression for up to 500 s, and the induced strain was imaged as a function of time. The strain was found to exhibit time-dependent spatially varying behaviour, which we interpret to be consistent with that of a heterogeneous poroelastic material. This occurred in both arms of all patients, although it was more easily seen in the ipsilateral (affected) arm than in the contralateral (apparently unaffected) arm in five out of the six patients. Further work would appear to be worthwhile to determine if poroelasticity imaging could be used in future both to diagnose lymphoedema and to explore the patho-physiology of the condition. PMID: 18222033 [PubMed - indexed for MEDLINE] ---------------------------------------------------------------------------- http://www.ncbi.nlm.nih.gov/pubmed/18077074?ordinalpos=31&itool=EntrezSystem2.PEntrez.Pubmed. Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum Ann Chir Plast Esthet. 2008 Apr;53(2):135-52. Epub 2008 Feb 20. Links [Post-treatment sequelae after breast cancer conservative surgery][Article in French] Delay E, Gosset J, Toussoun G, Delaporte T, Delbaere M. Unité de chirurgie plastique et reconstructrice, centre Léon-Bérard, 28, rue Laënnec, 69373 Lyon cedex 08, France. delay@lyon.fnclcc.fr Thanks to the earlier detection of breast cancer, the advent of neoadjuvant therapy and the development of more effective surgical procedures reducing treatment sequelae, conservative treatment has dramatically expanded over the past 15 years. Several factors have recognized negative aesthetic consequences for breast cancer patients: being overweight, having voluminous or on the contrary, very small breasts, having a tumor located in the lower quadrant, having high breast-tumor: breast-volume ratio. Tissue injuries induced by radiotherapy and chemotherapy, such as shrinking, fibrosis or induration, maximize the deleterious impact of surgery. The results of conservative treatment also deteriorate with time: weight gain is common and may result in increased breast asymmetry. Patients undergoing conservative treatment may experience sequelae including various degrees of the following dimorphisms, all possibly responsible for minor or even major breast deformity: breast asymmetry, loss of the nipple/areola complex, scar shrinkage and skin impairment, irregular shape and position of the nipple and areola. Various sensory symptoms have also been reported following conservative treatment, with patients complaining of hypo- or dysesthesia or even suffering actual pain. Breast lymphedema is also a common incapacitating after-effect that is believed to be largely underdiagnosed in clinical practice. Finally, like mastectomy, conservative breast surgery may induce serious psychological distress in patients who suffer the loss of physical integrity, womanhood or sexual arousal. Clinicians must be aware of the radiological changes indicative of late cancer recurrence. There are four types of modifications as follows: increased breast density, architectural distortion at the surgical site and formation of scar, mammary fat necrosis, and occurrence of microcalcifications. The management of sequelae of conservative breast treatment must therefore involve a multidisciplinary approach; patients not only expect better cosmetic appearance, but also a focus on other treatment advances such as improvement of psychological and sensory outcome. The interpretation of radiological images is also an integral part of the management of these patients at significant risk of recurrence. PMID: 18077074 [PubMed - indexed for MEDLINE] -------------------------------------------------------------------------- http://www.ncbi.nlm.nih.gov/pubmed/17928226?ordinalpos=32&itool=EntrezSystem2.PEntrez.Pubmed. Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum Breast. 2008 Apr;17(2):138-47. Epub 2007 Oct 24. Links Arm morbidity following sentinel lymph node biopsy or axillary lymph node dissection: a study from the Danish Breast Cancer Cooperative Group.Husted Madsen A, Haugaard K, Soerensen J, Bokmand S, Friis E, Holtveg H, Peter Garne J, Horby J, Christiansen P. Department of Surgery, Aarhus University Hospital, JageHansensgade 2, 8000 Aarhus C, Denmark. husted@ki.au.dk BACKGROUND: Sentinel lymph node biopsy was implemented in the treatment of early breast cancer with the aim of reducing shoulder and arm morbidity. Relatively few prospective studies have been published where the morbidity was assessed by clinical examination. Very few studies have examined the impact on shoulder mobility of node positive patients having a secondary axillary dissection because of the findings of metastases postoperatively. AIM: We aimed to investigate the objective and subjective arm morbidity in node negative and node positive patients. METHODS AND MATERIALS: In a prospective study, 395 patients with tumors less than 4 cm, were included. Patients were recruited from seven Danish breast cancer clinics. Both subjective and objective arm and shoulder morbidity were measured before, 6 and 18 months after the operation. RESULTS: Comparing node negative patients having a sentinel lymph node biopsy with node negative patients having a lymph node dissection of levels I and II of the axilla, we found significant increase in arm volume among the patients who had an axillary dissection. Only minor, but significant, differences in shoulder mobility were observed comparing the two groups of node negative patients. Highly significant difference was found comparing sensibility. Comparing the morbidity in node positive patients who had a one-step axillary dissection with patients having a two-step procedure (sentinel lymph node biopsy followed by delayed axillary dissection) revealed no difference in objective or subjective arm morbidity. CONCLUSION: Node negative patients operated with sentinel lymph node biopsy have less arm morbidity compared with node negative patients operated with axillary lymph node dissection. Node positive patients who had a secondary axillary lymph node dissection after sentinel lymph node biopsy had no difference in either objective or subjective morbidity compared with node positive patients having a one-step axillary dissection. PMID: 17928226 [PubMed - indexed for MEDLINE] --------------------------------------------------------------------------- http://www.ncbi.nlm.nih.gov/pubmed/17726597?ordinalpos=33&itool=EntrezSystem2.PEntrez.Pubmed. Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum Urologe A. 2008 Apr;47(4):472-6. Links [Penoscrotal elephantiasis: diagnostics and treatment options][Article in German] Zugor V, Horch RE, Labanaris AP, Schreiber M, Schott GE. Urologische Klinik mit Poliklinik, Friedrich-Alexander-Universität Erlangen-Nürnberg, Krankenhausstrasse 12, 91054 Erlangen, Deutschland. vahudin.zugor@uro.imed.uni-erlangen.de Penoscrotal elephantiasis is a symptom that can be caused by local but also by systemic disorders. When the changes are reversible, conservative measures such as physical and antiphlogistic approaches lead to success. In cases of irreversible penoscrotal elephantiasis, excision and amputation of the affected penoscrotal areas are recommended to eliminate the functional disturbances. In all manifestations it is important to prevent and treat those diseases known to cause elephantiasis. PMID: 17726597 [PubMed - indexed for MEDLINE] ------------------------------------------------------------------------------------- http://www.ncbi.nlm.nih.gov/pubmed/17680554?ordinalpos=34&itool=EntrezSystem2.PEntrez.Pubmed. Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum Psychooncology. 2008 Apr;17(4):392-400. Links Unmet needs of gynaecological cancer survivors: implications for developing community support services. Beesley V, Eakin E, Steginga S, Aitken J, Dunn J, Battistutta D. Institute of Health and Biomedical Innovation, School of Public Health, Queensland University of Technology, Brisbane, Australia. vanessa.beesley@qimr.edu.au After treatment completion, gynaecological cancer survivors may face long-term challenges and late effects, specific to this disease. Available research on supportive care needs of women with gynaecological cancer is limited. This study aimed to determine the prevalence and correlates of unmet needs within a population of gynaecological cancer survivors. Eight hundred and two women participated in a population-based mail survey in 2004 (56% response rate). The questionnaire included a validated instrument to assess 45 need items across multiple supportive care domains, and a range of measures to evaluate related correlates consistent with a social-ecological perspective. Forty-three per cent of respondents reported having at least one moderate- or high-level unmet need. The five highest included needing help with fear about the cancer spreading (17%), concerns about the worries of those close to them (15%), uncertainty about the future (14%), lack of energy/tiredness (14%), and not being able to do things they used to do (14%). Subgroups of women with higher odds of reporting 'some' unmet needs across multiple supportive care domains include those who, are not in remission, live with lymphoedema or are unable to work due to illness. Odds were also higher for women who had undergone more recent treatment, and who lived in rural or remote locations. Further assistance with the top specific concerns of gynaecological cancer survivors is recommended. Identified subgroups with higher needs are important targets for support. Copyright 2007 John Wiley & Sons, Ltd. PMID: 17680554 [PubMed - indexed for MEDLINE] --------------------------------------------------------------------- Epidemiol Infect. 2008 Apr;136(4):520-4. Epub 2007 Jun 20. Probability risk transmission matrix as a decision tool for assessing methods of transmission interruption of Wuchereria bancrofti infection.DAS PK, Vanamail P. Vector Control Research Centre, Pondicherry, India. vcrc@vsnl.com Lymphatic filariasis continues to cause severe morbidity and economic loss. The World Health Assembly (WHA) has passed a resolution to eliminate this disease by 2020. The major thrust of the elimination strategy is interrupting transmission by anti-parasitic treatment of entire communities. However, both vector density and community microfilaria load (CMFL) influence the intensity of transmission. Therefore, using a logistic regression approach a relationship has been established between the Risk of Infection Index (RII), vector density and CMFL. The present analysis indicates that there is no risk of transmission as long as the CMFL is maintained below 5 microfilaria (mf)/60 mm3 and the vector density per man-hour (MHD) is 25 and CMFL is <5 mf/60 mm3. In situations where CMFL is very high, parasitic control by mass administration may be cost effective in interrupting transmission. But at lower level of CMFL (<4 mf) and higher level of vector density it might be more cost effective to use vector control methods. A RII value <0.2 is considered to be the threshold for confirming interruption of transmission. Thus, the relationship has been depicted in the form of a probability matrix, which could be used for selecting an appropriate control strategy. PMID: 17579929 [PubMed - indexed for MEDLINE] Related ArticlesThe impact of six rounds of single-dose mass administration of diethylcarbamazine or ivermectin on the transmission of Wuchereria bancrofti by Culex quinquefasciatus and its implications for lymphatic filariasis elimination programmes. [Trop Med Int Health. 2003] The effect of six rounds of single dose mass treatment with diethylcarbamazine or ivermectin on Wuchereria bancrofti infection and its implications for lymphatic filariasis elimination. [Trop Med Int Health. 2002] Randomised community- based trial of annual single-dose diethylcarbamazine with or without ivermectin against Wuchereria bancrofti infection in human beings and mosquitoes. [Lancet. 1998] Impact of 10 years of diethylcarbamazine and ivermectin mass administration on infection and transmission of lymphatic filariasis. [Trans R Soc Trop Med Hyg. 2007] Vector control complements mass drug administration against bancroftian filariasis in Tirukoilur, India. [Bull World Health Organ. 2007] » See all Related Articles... http://www.ncbi.nlm.nih.gov/pubmed/17579929?ordinalpos=35&itool=EntrezSystem2.PEntrez.Pubmed. Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum ---------------------------------------------------------------------------------------------------- MAY 2008 LYMPHEDEMA ABSTRASTS Plast Reconstr Surg. 2008 May;121(5):1811-20. J Surg Oncol. 2008 May 5 [Epub ahead of print] Prospective trial of intensive decongestive physiotherapy for upper extremity lymphedema. Karadibak D, Yavuzsen T, Saydam S. School of Physical Therapy and Rehabilitation, Dokuz Eylul University, Izmir, Turkey. BACKGROUND: The aim of this study was to evaluate the effects of kinesiophobia, quality of life, and home exercise programs on women with upper extremity lymphedema. METHODS: A total of 62 women with lymphedema after breast cancer treatments were provided a protocol of complete decongestive therapy (CDT). This protocol involved manual lymphatic drainage (MLD), compression garments, skin care, and remedial exercises. The women were taken to a 12-week therapy program once per day, 3 days per week. A home program, consisting of compression bandage exercises, skin care and walking was recommended. Absolute volume and percentage of volume of the lymphedema were compared before and after treatment. The kinesiophobia, quality of life, and home-based program were assessed before and after physiotherapy. RESULTS: Strong correlations were found between the severity of edema and fear of movement. There was a significant negative relationship among the fear of movement, quality of life, and home-based exercises program. Mean initial lymphedema volume was 925 ml, and the percentage of lymphedema was 47.1%. After decongestive physiotherapy, the lymphedema volume and percentage were 510 ml and 21.3% (P < 0.05), respectively. There was also a trend toward improvement in general well-being (P < 0.05). CONCLUSION: In upper extremity lymphedema, the use of complex physiotherapy programs (CDP) can decrease edema and fear of activity, and increase the quality of life. J. Surg. Oncol. (c) 2008 Wiley-Liss, Inc. PMID: 18459131 [PubMed - as supplied by publisher] Complications after polymethylmethacrylate injections: report of 32 cases. Salles AG, Lotierzo PH, Gemperli R, Besteiro JM, Ishida LC, Gimenez RP, Menezes J, Ferreira MC. Division of Plastic Surgery, Faculty of Medicine, University of São Paulo, Brazil. agsalles@uol.com.br BACKGROUND: During the past 15 years, polymethylmethacrylate has been used as a synthetic permanent filler for soft-tissue augmentation. METHODS: This article reports 32 cases of complications seen at Hospital das Clínicas, Faculty of Medicine, University of São Paulo, for procedures performed elsewhere. RESULTS: The average age of the patients was 43.6 years (range, 22 to 70 years). Twenty- five patients were women. Sixteen injection procedures were performed by certified plastic surgeons, nine by dermatologists, two by urologists, and one by a nonphysician. Complications were classified into five groups according to main presentation as follows: tissue necrosis (five cases), an acute complication that can be related to technical mistakes but that can also be dependent on patient factors or caused by local infection; granuloma (10 cases), which usually presents as a subacute complication 6 to 12 months after the procedure; chronic inflammatory reactions (10 cases), which usually occur years later and can be related to a triggering event, such as another operation or infection in the area that was injected (these reactions are immunogenic in origin and may have cyclic periods of activation and remission); chronic inflammatory reaction in the lips (six cases), which may be present with severe symptoms, especially with lymphedema, because of mobility of the lip; and infections (one case), which are rare but possible complications after filling procedures. CONCLUSIONS: Polymethylmethacrylate filler complications, despite being rare, are often permanent and difficult or even impossible to treat. Safety guidelines should be observed when considering use of polymethylmethacrylate for augmentation. PMID: 18454007 [PubMed - in process]http://www.ncbi.nlm.nih.gov/pubmed/18454007? dopt=Abstract ====================================================================== ================ Microvasc Res. 2008 Mar 20 [Epub ahead of print] MR lymphangiography for the assessment of the lymphatic system in patients undergoing microsurgical reconstructions of lymphatic vessels. Lohrmann C, Felmerer G, Foeldi E, Bartholomä JP, Langer M. Department of Radiology, University Hospital of Freiburg, Hugstetter Strasse 55, D-79106, Freiburg, Germany. OBJECTIVE: To assess the morphology of the lymphatic system pre- and postoperatively in patients undergoing microsurgical reconstructions of the lymphatic vessels. MATERIALS AND METHODS: 8 lower extremities in 4 consecutive patients with secondary unilateral lymphedema of the lower extremities were examined by MR lymphangiography. 18 mL of gadoteridol and 1 mL of mepivacainhydrochloride 1% were subdivided into 10 portions and injected intracutaneously into the dorsal aspect of each foot at the region of the four interdigital webs and medial to the first proximal phalanx. MR imaging was performed with a 1.5-T system equipped with high-performance gradients. For MR lymphangiography a 3D-spoiled gradient-echo sequence was used. For evaluation of the lymphedema a heavily T2-weighted 3D-TSE sequence was performed. RESULTS: In 2 patients the 3D-TSE sequence demonstrated a decrease of the epifascial lymphedema in the postoperative acquisitions, whereby MR lymphangiography displayed an improvement of dermal-back areas and collateral lymphatic vessels. In one patient the epifascial lymphedema of the lower extremity decreased, whereas the diameter of the lymphatic vessels showed a constant diameter of 2 mm. In one patient with a lymphocutaneous fistula at the level of the right groin, the feeding lymphatic vessels and contrast media extravasation could clearly be visualized. The 3D-TSE sequence demonstrated an epi- as well as subfascial lymphedema of the right leg. CONCLUSION: MR lymphangiography is a safe and accurate diagnostic imaging method for the pre- and postoperative evaluation of the lymphatic circulation in patients undergoing microlymphatic surgery. Due to the minimal-invasiveness and lack of radiation, diagnostic follow-up MR lymphangiography examinations can be performed routinely and with no risk for the patient. PMID: 18456290 [PubMed - as supplied by publisher]http://www.ncbi.nlm.nih.gov/pubmed/18456290? dopt=Abstract ====================================================================== ========= Pediatr Dev Pathol. 2008 May 1;:1 [Epub ahead of print] Primary mesenteric angiosarcoma in a child with associated lymphangectasia: a case report. Costa da Cunha Castro E, Galambos C, Shaw P, Ranganathan S. Angiosarcomas are rare tumors in children, usually occurring in soft tissue and liver. By contrast, angiosarcoma in adults usually occurs in the extremities in conjunction with lymphedema. Mesenteric angiosarcoma has only rarely been reported. When angiosarcomas arise in this location, it is usually as a second malignancy following Hodgkin's lymphoma. We report a child who presented to the emergency room with a acute abdomen and underwent emergency surgery for a mesenteric angiosarcoma with associated lymphangectasia of the bowel and mesentery. A brief review of the literature and the nomenclature of these unusual tumors are discussed. PMID: 18452347 [PubMed - as supplied by publisher]http://www.ncbi.nlm.nih.gov/pubmed/18452347? dopt=Abstract ====================================================================== ================== Breast. 2008 Apr 29 [Epub ahead of print] Postmastectomy neuropathic pain: Results of microsurgical lymph nodes transplantation. Becker C, Pham DN, Assouad J, Badia A, Foucault C, Riquet M. Service de Chirurgie Thoracique, Hôpital Européen Georges Pompidou, 20-40 rue Leblanc, 75015 Paris Cedex, France. Postmastectomy chronic pain may be divided into widespread and regional pain. Almost half patients with regional pain, which is more likely related to neuropathic phenomena, do not benefit any pain relief from medication. Our purpose was to report results on pain relief obtained by axillary lymph nodes autotransplantation. METHODS: Six patients presented with chronic regional neuropathic pains and upper limb lymphedema after breast cancer surgery and radiation therapy. Despite medication, pain was intolerable and daily activity dramatically reduced. Lymph nodes were harvested in the femoral region, transferred to the axillary region and transplanted by microsurgical procedures. RESULTS: Lymphedema resolved in 5 out of 6 patients. Pain was relieved in all, permitting return to work and daily activity; analgesic medication was discontinued. CONCLUSION: This procedure proved efficient and may be advocated in case of neuropathic pain when discussing lymphedema management. PMID: 18450444 [PubMed - as supplied by publisher] http://www.ncbi.nlm.nih.gov/pubmed/18450444?dopt=Abstract --------------------------------------------------------------------------------------------- Vascul Pharmacol. 2008 Mar 10 [Epub ahead of print] Effect of vascular endothelial growth factor C (VEGF-C) gene transfer in rat model of secondary lymphedema. Liu Y, Fang Y, Dong P, Gao J, Liu R, Hhahbaz M , Bi Y, Ding Z, Tian H, Liu Z. Department of Anatomy, Shandong University School of Medicine, Jinan, 250012, China. Secondary lymphedema has been clinically well described, but a cure is still lacking. Although there have been previous investigations using plasmid DNA for gene therapy, few have focused on the use for the treatment of lymphedema. Therefore, we investigated the effects of VEGF-C gene transfer for the treatment of lymphedema using our plasmid pcDNA3.1-VEGF-C. We produced a surgical model of secondary lymphedema in the rat hindlimb and treated with local intradermal VEGF-C transfection to investigate the efficacy of gene transfer. Magnetic resonance imaging (MRI) (P<0.05), B ultrasound (P<0.05), and water displacement volumetry (P<0.05) demonstrated a reduction of lymphedema in therapy group as compared to controls. Histological and immunofluorescent studies demonstrated numerous newly formed lymphatic vessels in therapy group. Our results indicate that VEGF-C gene therapy has produced new lymphatic vessels which may have improved functional lymphatic drainage to reduce lymphedema volume in our model. PMID: 18455964 [PubMed - as supplied by publisher]http://www.ncbi.nlm.nih.gov/pubmed/18455964? dopt=Abstract ====================================================================== ==================== http://www.meadvilletribune.com/multimedia/local_story_129234613.html? keyword=topstory&appSession=71589429255362 Blood. 2008 May 12. [Epub ahead of print]Related Articles, Links Role of VEGF-D and VEGFR-3 in developmental lymphangiogenesis, a chemicogenetic study in Xenopus tadpoles. Ny A, Koch M, Vandevelde W, Schneider M, Fischer C, Diez-Juan A, Neven E, Geudens I, Maity S, Moons L, Plaisance S, Lambrechts D, Carmeliet P, Dewerchin M. Department of Transgene Technology and Gene Therapy, VIB, K.U.Leuven, Leuven, Belgium. The importance of the lymphangiogenic factor VEGF-D and its receptor VEGFR-3 in early lymphatic development remains largely unresolved. We therefore investigated their role in Xenopus laevis tadpoles, a small animal model allowing chemicogenetic dissection of developmental lymphangiogenesis. Single morpholino antisense oligo knockdown of VEGF-D did not affect lymphatic commitment, but transiently impaired lymphatic endothelial cell (LEC) migration. Notably, combined knockdown of VEGF-D with VEGF-C at suboptimal morpholino concentrations, resulted in more severe migration defects and lymphedema formation than the corresponding single knockdowns. Knockdown of VEGFR-3 or treatment with the VEGFR-3 inhibitor MAZ51 similarly impaired lymph vessel formation and function and caused pronounced edema. VEGFR-3 silencing by morpholino knockdown, MAZ51 treatment, or VEGF-C/D double knockdown also resulted in dilation and dysfunction of the lymph heart. These findings document a critical role of VEGFR-3 in embryonic lymphatic development and function, and reveal a previously unrecognized modifier role of VEGF-D in the regulation of embryonic lymphangiogenesis in frog embryos. PMID: 18474726 [PubMed - as supplied by publisher] http://www.ncbi.nlm.nih.gov/pubmed/18474726?dopt=Abstract -------------------------------------------------------------------------------- J Am Coll Surg. 2008 May;206(5):1038-42; discussion 1042-4. Epub 2008 Mar 3. Axillary reverse mapping: mapping and preserving arm lymphatics may be important in preventing lymphedema during sentinel lymph node biopsy. Boneti C, Korourian S, Bland K, Cox K, Adkins LL, Henry-Tillman RS, Klimberg VS. Division of Breast Surgical Oncology, Department of Surgery, University of Arkansas for Medical Sciences, Winthrop P Rockefeller Cancer Institute, Little Rock, AR, USA. BACKGROUND: Several recent reports have shown a lymphedema rate of about 7% with sentinel lymph node biopsy (SLNB) only. We hypothesized that this higher than expected rate of lymphedema may be secondary to disruption of arm lymphatics during an SLNB procedure. STUDY DESIGN: This IRB-approved study, from May 2006 to June 2007, involved patients undergoing SLNB with or without axillary lymph node dissection. After sentinel lymph node (SLN) localization with subareolar technetium was assured, 2 to 5 mL of dermal blue dye was injected in the upper inner arm for localization of lymphatics draining the arm (axillary reverse mapping, ARM). The SLNB was then performed through an incision in the axilla. Data were collected on identification rates of hot versus blue nodes, variations in ARM lymphatic drainage that might impact SLNB, crossover between the hot and the blue lymphatics, and final pathologic nodal diagnosis. RESULTS: Median age was 57.6+/-12.5 years. Lymphatics draining the arm were near or in the SLN field in 42.7% (56 of 131) of the patients, placing the patient at risk for disruption if not identified and preserved during an SLNB or axillary lymph node dissection. ARM demonstrated that arm lymphatics do not cross over with the SLN drainage of the breast 96.1% of the time and that none of the ARM lymph nodes removed were positive, even when the SLN was (5 of 12). Seven (5.5%) blue ARM lymphatics were juxtaposed to the hot SLNBs. CONCLUSIONS: Disruption of the blue ARM node because of proximity to the hot SLN may explain the surprisingly high rate of lymphedema seen after SLNB. Identifying and preserving the ARM blue nodes may translate into a lower incidence of lymphedema with SLNB and axillary lymph node dissection. PMID: 18471751 [PubMed - in process] http://www.ncbi.nlm.nih.gov/pubmed/18471751?dopt=Abstract --------------------------------------------------------------------------------------- J Reprod Med. 2008 Apr;53(4):299-301. Recurrent vulvar lymphangitis cured with vulvectomy in a cervical carcinoma patient: a case report. Micha JP, Goldstein BH, Rettenmaier MA, Tinnerman-Minailo EJ, Brown JV 3rd, McClellan SN, Bock BV. Gynecologic Oncology Associates, Hoag Cancer Center, Newport Beach, California 92663, USA. BACKGROUND: Recurrent vulvar lymphangitis secondary to pelvic lymphadenectomy and radiation therapy can be a vexing clinical dilemma. CASE: A 55-year-old woman was initially treated with radical hysterectomy and 1 postoperative radiotherapy for cervical carcinoma in 1984. In 1987 she developed persistent vulvar, leg, and ankle edema; chronic vulvar pain; and recurrent vulvar cellulitis, which were ultimately attributed to group B Streptococcus. Despite long-term antibiotic therapy and compression stockings, the cellulitis was intractable. In June 2006 the patient underwent a bilateral simple vulvectomy with preservation of the clitoris and insertion of bilateral subcutaneous Jackson-Pratt drains. Her postoperative culture results revealed normal vaginal flora. CONCLUSION: The patient's wounds healed very well, and she has had no further episodes of vulvitis or lymphangitis. The management of recurrent infections involving lymphedema can be difficult and cause complicated clinical issues. Publication Types: Research Support, Non-U.S. Gov't PMID: 18472655 [PubMed - in process] http://www.ncbi.nlm.nih.gov/pubmed/18472655?dopt=Abstract ----------------------------------------------------------------------------------- Gynecol Oncol. 2008 May 13. [Epub ahead of print] A randomized phase III trial of VH fibrin sealant to reduce lymphedema after inguinal lymph node dissection: A Gynecologic Oncology Group study. Carlson JW, Kauderer J, Walker JL, Gold MA, O'Malley D, Tuller E, Clarke-Pearson DL. Gynecologic Oncology of West Michigan, Grand Rapids, MI, USA. OBJECTIVES: To evaluate VH fibrin sealant's influence on lower extremity lymphedema after inguinal lymphadenectomy in vulvar cancer patients. METHODS: Patients undergoing an inguinal lymphadenectomy during the management of vulvar malignancy were randomized to receive sutured closure (SC) vs VH fibrin sealant sprayed into the groin followed by sutured closure (FS). Leg measurements were taken preoperatively and during postoperative encounters when surgical outcomes were assessed. Grade 2 or 3 lymphedema was defined as circumferential measurement increases of 3-5 cm and >5 cm, respectively. RESULTS: 150 patients were enrolled. 137 patients were evaluable for lymphedema analysis with 67 and 70 patients in the SC arm and FS arm, respectively. The incidence of grade 2 and 3 lymphedema was 67%(45/67) in the SC arm, and 60% (42/70) FS arm (p=0.4779). The incidence of lymphedema was strongly associated with inguinal infection (p=0.0165). Lymphedema was not statistically increased in those who received adjuvant radiation. 139 patients remained evaluable for a descriptive analysis of their surgical complications. The overall incidence of complications was 61% (43/70) and 59% (41/69) for SC and FS arms, respectively. There was no statistically significant difference in duration of drains, drain output or incidence of inguinal infections, wound breakdowns or seromas. There was an increased incidence of vulvar infections in the FS arm (23/69) vs (10/70) (p=0. 0098). The utilization of a Blake drain was associated with an increase in vulvar (p=0.0157) and inguinal wound breakdown (p=0.0456). CONCLUSION: VH fibrin sealant in inguinal lymphadenectomies does not reduce leg lymphedema and may increase the risk for complications in the vulvar wound. PMID: 18482765 [PubMed - as supplied by publisher] http://www.ncbi.nlm.nih.gov/pubmed/18482765?dopt=Abstract -------------------------------------------------------------------------------------------- J Clin Nurs. 2008 Jun;17(11):1450-9. Incidence and risk factors of breast cancer lymphoedema. Park JH, Lee WH, Chung HS. College of Nursing, Ajou University, Seoul, Korea. jhee@ajou.ac.kr AIM: The purpose of this study was to examine the incidence of lymphoedema and to identify risk factors of lymphoedema in patients with breast cancer undergoing mastectomy in Korea. BACKGROUND: Lymphoedema is a serious problem for many breast cancer survivors. Although the potential impact of lymphoedema is extensive, it is largely unrecognised. METHODS: Women with breast cancer (n = 450) receiving mastectomy were recruited from outpatient breast cancer clinics of two university hospitals in Seoul, Korea from October 2004 to May 2005. Lymphoedema was defined by circumferential measurement. This study examined the risk factors associated with lymphoedema through the literature review. A descriptive design was used for this study and data were collected using structured questionnaire. Data were analysed by chi-square test and multiple logistic regression. RESULTS: Among the 450 cases of breast cancer, 24.9% had developed lymphoedema. There were significantly increased risks of lymphoedema if women were with higher staging, had modified radical mastectomy, had axillary lymph node dissection, received axillary radiotherapy and were with body mass index greater than 25 kg/m(2). A significantly decreased risk of lymphoedema was found in women who exercised regularly, received pretreatment education of lymphoedema and had performed preventive self- care activities. CONCLUSIONS: Lymphoedema is recognised as an unpleasant and uncomfortable consequence of breast cancer-related treatment. Patients should be advised of the risk of lymphoedema and educated to detect its symptoms. Relevance to clinical practice. It is of importance to recognise breast cancer patients at risk for lymphoedema. Nurses should inform patients with breast cancer about their risk for lymphoedema and guidelines to reduce the risk and to emphasise self-care activities for prevention. PMID: 18482142 [PubMed - in process] -------------------------------------------------------------------------------------------- Br J Dermatol. 2008 Jun;158(6):1175-6. Lymphoedema and cellulitis: chicken or egg? Keeley VL. Publication Types: Editorial PMID: 18482406 [PubMed - in process] http://www.ncbi.nlm.nih.gov/pubmed/18482406?dopt=Abstract British Journal of Dermatology Volume 158 Issue 6 Page 1175-1176, June 2008 To cite this article: V.L. Keeley (2008) Lymphoedema and cellulitis: chicken or egg? British Journal of Dermatology 158 (6) , 1175–1176 doi:10.1111/j.1365-2133.2008.08590.x EDITORIAL Lymphoedema and cellulitis: chicken or egg? V.L. KeeleyDerby Hospitals NHS Foundation Trust, Nightingale Macmillan Unit, Derby DE1 2QS, U.K. E-mail: Vaughan.keeley@derbyhospitals.nhs.uk ---------------------------------------------------------------------------------- Pediatr Transplant. 2008 May 23. [Epub ahead of print] Successful living-related liver transplantation in a child with familial yellow nail syndrome and fulminant hepatic failure: Report of a case. Kuloglu Z, Ustündag G, Kirsaçlioglu CT, Kansu A, Bingol-Kologlu M, Vargun R, Hazinedaroglu S, Karayalçin S, Girgin N. Department of Pediatric Gastroenterology, School of Medicine, Ankara University, Ankara, Turkey. An 11-yr-old boy with familial YNS and FHF and who underwent LRLT is presented. LRLT was performed from his father with YNS. The findings of hepatic failure resolved immediately after LRLT, but severe respiratory complications and chylous ascites were observed during the follow-up. At 12 months after successful LT, the patient has good graft function, but findings of YNS including chronic cough, lymphedema and yellow nails are still present. To the best of our knowledge, this is the first case of YNS who underwent LRLT for FHF. PMID: 18503484 [PubMed - as supplied by publisher] http://www.ncbi.nlm.nih.gov/pubmed/18503484?dopt=Abstract -------------------------------------------------------------------------------- Br J Dermatol. 2008 May 22. [Epub ahead of print]s Phacomatosis spilorosea associated with lymphoedema. Jordaan HF, Happle R. Department of Dermatology, University of Stellenbosch and Tygerberg Hospital, Stellenbosch, South Africa. PMID: 18503593 [PubMed - as supplied by publisher http://www.ncbi.nlm.nih.gov/pubmed/18503593?dopt=Abstract ====================================================================== ============= Int Angiol. 2008 Jun;27(3):193-219. Indications for compression therapy in venous and lymphatic disease Consensus based on experimental data and scientific evidence. Under the auspices of the IUP. Partsch H, Flour M, Coleridge Smith P. Dermatology and Angiology, Medical University of Vienna, Baumeistergasse 85, A 1160 Vienna, Austria Hugo.Partsch@meduniwien.ac.at. AIM: The aim of this study was to review published literature concerning the use of compression treatments in the management of venous and lymphatic diseases and establish where reliable evidence exists to justify the use of medical compression and where further research is required to address areas of uncertainty. METHODS: The authors searched medical literature databases and reviewed their own collections of papers, monographs and books for papers providing information about the effects of compression and randomized clinical trials of compression devices. Papers were classified in accordance with the recommendations of the GRADE group to categorize their scientific reliability. Further classification was made according to the particular clinical problem that was addressed in the papers. The review included papers on compression stockings, bandages and intermittent pneumatic compression devices. RESULTS: The International Compression Club met once in Vienna and corresponded by email in order to reach an agreement of how the data should be interpreted. A wide range of compression levels was reported to be effective. Low levels of compression 10-30 mmHg applied by stockings are effective in the management of telangiectases after sclerotherapy, varicose veins in pregnancy, the prevention of edema and deep vein thrombosis (DVT). High levels of compression produced by bandaging and strong compression stockings (30-40 mmHg) are effective at healing leg ulcers and preventing progression of post-thrombotic syndrome as well as in the management of lymphedema. In some areas no reliable evidence was available to permit recommendations of level of compression or duration of treatment. These included: management of varicose veins to prevent progression, following surgical treatment or sclerotherapy for varicose veins, and the level of compression required to treat acute DVT. CONCLUSION: This review shows that whilst good evidence for the use of compression is available in some clinical indications, there is much still to be discovered. Little is know about dosimetry in compression, for how long and at what level compression should be applied. The differing effects of elastic and short-stretch compression are also little understood. PMID: 18506124 [PubMed - in process] http://www.ncbi.nlm.nih.gov/pubmed/18506124?dopt=Abstract ====================================================================== =================== ol Cell Biol. 2008 Aug;28(15):4843-50. Epub 2008 Jun 2. Deletion of vascular endothelial growth factor C (VEGF-C) and VEGF-D is not equivalent to VEGF receptor 3 deletion in mouse embryos. Haiko P, Makinen T, Keskitalo S, Taipale J, Karkkainen MJ, Baldwin ME, Stacker SA, Achen MG, Alitalo K. Molecular/Cancer Biology Laboratory, Haartman Institute, Biomedicum Helsinki and Helsinki University Central Hospital, P. O. B. 63 (Haartmaninkatu 8), University of Helsinki, 00014 Helsinki, Finland. Lymphatic vessels play an important role in the regulation of tissue fluid balance, immune responses, and fat adsorption and are involved in diseases including lymphedema and tumor metastasis. Vascular endothelial growth factor (VEGF) receptor 3 (VEGFR-3) is necessary for development of the blood vasculature during early embryogenesis, but later, VEGFR-3 expression becomes restricted to the lymphatic vasculature. We analyzed mice deficient in both of the known VEGFR-3 ligands, VEGF-C and VEGF-D. Unlike the Vegfr3(-/-) embryos, the Vegfc(-/-); Vegfd(-/-) embryos displayed normal blood vasculature after embryonic day 9.5. Deletion of Vegfr3 in the epiblast, using keratin 19 (K19) Cre, resulted in a phenotype identical to that of the Vegfr3(-/-) embryos, suggesting that this phenotype is due to defects in the embryo proper and not in placental development. Interestingly, the Vegfr3(neo) hypomorphic mutant mice carrying the neomycin cassette between exons 1 and 2 showed defective lymphatic development. Overexpression of human or mouse VEGF-D in the skin, under the K14 promoter, rescued the lymphatic hypoplasia of the Vegfc(+/-) mice in the K14-VEGF-D; Vegfc(+/-) compound mice, suggesting that VEGF-D is functionally redundant with VEGF-C in the stimulation of developmental lymphangiogenesis. Our results suggest VEGF-C- and VEGF-D-independent functions for VEGFR-3 in the early embryo. Publication Types: Research Support, N.I.H., Extramural Research Support, Non-U.S. Gov't PMID: 18519586 [PubMed - indexed for MEDLINE] PMCID: PMC2493372 [Available on 12/01/08] _______________________________________________________________________________ _ Arch Surg. 2008 Jun;143(6):575-80; discussion 581. Modified radical mastectomy with axillary dissection using the electrothermal bipolar vessel sealing system. Manouras A, Markogiannakis H, Genetzakis M, Filippakis GM, Lagoudianakis EE, Kafiri G, Filis K, Zografos GC. First Department of Propaedeutic Surgery, Hippokrateion Hospital, Athens Medical School, University of Athens, Athens, Greece. HYPOTHESIS: The use of the electrothermal bipolar vessel sealing system is feasible, safe, and effective in modified radical mastectomy with axillary dissection in terms of lymph vessel sealing, hemostasis, and perioperative complications. DESIGN: Prospective study. SETTING: University surgical department. PATIENTS: Between January 1, 2003, and December 31, 2003, 60 patients with locally advanced breast cancer (T2 or T3) admitted for modified radical mastectomy with axillary dissection were included in this study. The entire procedure was performed by the same surgical team using the electrothermal bipolar vessel sealing system. MAIN OUTCOME MEASURES: Final outcome, operative time, hospitalization stay duration, intraoperative blood loss, postoperative mastectomy and axillary drainage volume and duration, and postoperative complications (seroma, bleeding, skin burn, hematoma, lymphedema, pneumothorax, and wound infection or necrosis). RESULTS: The mean (SD) intraoperative blood loss was 45 (12) mL, and the mean (SD) operative time was 105 (7) minutes. No postoperative bleeding, seroma, hematoma, lymphedema, or other complications occurred. The mean (SD) mastectomy and axillary drainage volumes were 20 (8) and 155 (35) mL, respectively, and the mean (SD) drainage durations were 1.3 (0.2) and 2.7 (0.5) days, respectively. The mean (SD) hospital stay was 3.7 (0.6) days. CONCLUSIONS: In this first report (to our knowledge) of modified radical mastectomy with axillary dissection using the electrothermal bipolar vessel sealing system, the technique was feasible, safe, and effective. The device simplified the surgical procedure, while achieving efficient lymph vessel sealing and hemostasis. Compared with historical data regarding the conventional or harmonic scalpel, this technique seems to result in reduced operative time, perioperative blood loss, drainage volume and duration, and incidence of seroma or lymphedema. Prospective randomized controlled studies are necessary to evaluate the effect of this technique on perioperative complications. Publication Types: Comparative Study PMID: 18559751 [PubMed - indexed for MEDLINE] _______________________________________________________________________________ _ J Cutan Pathol. 2008 Jun 17. [Epub ahead of print] Localized lymphedema (elephantiasis): a case series and review of the literature. Lu S, Tran TA, Jones DM, Meyer DR, Ross JS, Fisher HA, Carlson JA. Department of Pathology and Laboratory Medicine, Albany Medical College, Albany, NY, USA. Background: Lymphedema typically affects a whole limb. Rarely, lymphedema can present as a circumscribed plaque or an isolated skin tumor. Objective: To describe the clinical and pathologic characteristics and etiologic factors of localized lymphedema. Methods: Case-control study of skin biopsy and excision specimens histologically diagnosed with lymphedema and presenting as a localized skin tumor identified during a 4-year period. Results: We identified 24 cases of localized lymphedema presenting as solitary large polyps (11), solid or papillomatous plaques (7), pendulous swellings (4), or tumors mimicking sarcoma (2). Patients were 18 females and 6 males with a mean age of 41 years (range 16-74). Anogenital involvement was most frequent (75%) - mostly vulva (58%), followed by eyelid (13%), thigh (8%) and breast (4%). Causative factors included injury due to trauma, surgery or childbirth (54%), chronic inflammatory disease (rosacea, Crohn's disease) (8%), and bacterial cellulitis (12%). Eighty-five percent of these patients were either overweight (50%) or obese (35%). Compared with a series of 80 patients with diffuse lymphedema, localized lymphedema patients were significantly younger (41 vs. 62 years old, p = 0.0001), had no history of cancer treatment (0% vs. 18%, p = 0.03), and had an injury to the affected site (54% vs. 6%, p = 0.0001). Histologically, all cases exhibited dermal edema, fibroplasia, dilated lymphatic vessels, uniformly distributed stromal cells and varying degrees of papillated epidermal hyperplasia, inflammatory infiltrates and hyperkeratosis. Tumor size significantly and positively correlated with history of cellulitis, obesity, dense inflammatory infiltrates containing abundant plasma cells, and lymphoid follicles (p < 0.05). A history of cellulitis, morbid obesity, lymphoid follicles and follicular cysts predicted recurrent or progressive swelling despite excision (p < 0.05). Conclusions: Localized lymphedema should be considered in the etiology of skin tumors when assessing a polyp, plaque, swelling or mass showing dermal edema, fibrosis and dilated lymphatics on biopsy. A combination of lymph stasis promoting factors (trauma, obesity, infection and/or inflammatory disorders) produces localized elephantiasis. PMID: 18564285 [PubMed - as supplied by publisher] _______________________________________________________________________________ _ Breast Cancer Res Treat. 2008 Jun 18. [Epub ahead of print] Single frequency versus bioimpedance spectroscopy for the assessment of lymphedema. York SL, Ward LC, Czerniec S, Lee MJ, Refshauge KM, Kilbreath SL. Faculty of Health Sciences, University of Sydney, P.O. Box 170, East Street, 2141, Lidcombe, NSW, Australia. Background The aims were to determine (i) whether single frequency bioimpedance analysis (SFBIA) is as accurate as bioimpedance spectroscopy (BIS) in measurement of extracellular fluid and (ii) whether change in extracellular fluid was specific to only the limb directly affected by surgery. Methods Arms of the control (n = 28) and arm lymphedema group (n = 28) and legs of the leg lymphedema group (n = 16) were assessed with SFBIA. All four limbs in all participants were assessed with BIS. All measurements occurred in a single session. Results BIS-measured ratios were highly concordant with those obtained with SFBIA (r (c) = 0.99, P < 0.001). Repeated measures ANOVA revealed that the ratio involving the lymphedema limb was different to the ratio of the non-oedematous limbs which was not significantly different to the arm or leg ratios of the control group. Conclusions SFBIA is a simple accurate alternative to BIS for the clinical assessment of unilateral lymphedema. BIS discriminates those with clinical diagnosis of unilateral lymhoedema from those without the diagnosis. PMID: 18563555 [PubMed - as supplied by publisher] _______________________________________________________________________________ _ Virchows Arch. 2008 Aug;453(2):217-9. Epub 2008 Jun 17. Chronic lymphedema due to morbid obesity: an exceptional cause of abdominal wall angiosarcoma. Salas S, Stock N, Stoeckle E, Kind M, Bui B, Coindre JM. Departments of Pathology, Institut Bergonié. 229, cours de l'Argonne, 33076, Bordeaux Cedex, France. PMID: 18560886 [PubMed - in process] _______________________________________________________________________________ _ Lymphology. 2008 Jun;41(2):80-6. Study of edema reduction patterns during the treatment phase of complex decongestive physiotherapy for extremity lymphedema. Yamamoto T, Todo Y, Kaneuchi M, Handa Y, Watanabe K, Yamamoto R. Rhythmic Obstetrics and Gynecology Clinic, Hokkaido University Graduate School of Medicine, Sapporo, Japan. Shortening the treatment phase of complex decongestive physiotherapy (CDP) is extremely important both for individual patients and medical economics. In 83 patients with stage II unilateral secondary extremity lymphedema (31 upper extremities and 52 lower extremities), the daily changes in the volume of affected extremities during the treatment phase of CDP were prospectively investigated. For the upper extremity lymphedemas, the biggest change was seen between days 1 (100% residual edema rate) and 2 (46.0 +/- 2.7%; mean +/- SD) of therapy with a 54.0% reduction (p < 0.0001). Between days 2 and 3 (38.0 +/- 2.6%) of therapy, there was an 8.0% reduction (p < 0.05). From days 3 to 6 of therapy, slight changes ranging from 0.2 to 3.2%/day were seen. For the lower extremity lymphedemas, the biggest change was seen between days 1 (100%) and 2 (44.5 +/- 2.1%) of therapy with a 55.5% reduction (p < 0.0001). Between days 2 and 3 (33.5 +/- 2.6%) of therapy, there was an 11.0% reduction (p < 0.001). The daily volume changes from days 4 to 6 were slight, ranging from 0.1 to 1.0%/day. During the treatment phase of CDP, the largest volume changes were seen soon after the start of therapy. PMID: 18720915 [PubMed - indexed for MEDLINE] _______________________________________________________________________________ _ Lymphology. 2008 Jun;41(2):52-63. Controlled compression and liposuction treatment for lower extremity lymphedema. Brorson H, Ohlin K, Olsson G, Svensson B, Svensson H. Department of Clinical Sciences Malmö, Lund University, Plastic and Reconstructive Surgery, Malmö University Hospital, Malmö, Sweden. hakan.brorson@med.lu.se Department of Clinical Sciences Malmö, Lund University, Plastic and Reconstructive Surgery, Malmö University Hospital, Malmö, Sweden. hakan.brorson@med.lu.se In 1987 we noticed excess adipose tissue in a patient with arm lymphedema and later, objective studies confirmed this clinical finding in patients with non-pitting arm lymphedema following breast cancer. A prospective study was begun in 1993, and its long-term results (15 years) shows overall complete reduction of the excess volume in patients with non-pitting arm lymphedema and that adipose tissue dominates the excess volume. Encouraged by these results we operated on a patient with primary and secondary elephantiasis of the leg. The edema was first transferred from a pitting to a non-pitting state by controlled compression therapy. Then liposuction was performed to remove the remaining excess adipose tissue, and complete reduction was finally achieved. The patient wears compression garments continuously and during the 11 years of followup, no recurrence has occurred. This paper explains our philosophical approach: a pitting lymphedema first should be treated conservatively to remove excess fluid, then liposuction can be performed to remove remaining excess volume bothersome to the patient. Publication Types: Case Reports PMID: 18720912 [PubMed - indexed for MEDLINE] _______________________________________________________________________________ _ Ultrasound Obstet Gynecol. 2008 Jul;32(1):87-90. Natural history of pelvic lymphocysts as observed by ultrasonography after bilateral pelvic lymphadenectomy. Tam KF, Lam KW, Chan KK, Ngan HY. Department of Obstetrics and Gynaecology, Gynaecological Oncology Division, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China. tamkfa@netvigator.com OBJECTIVES: To determine, in patients who have undergone bilateral pelvic lymphadenectomy for gynecological cancer, the incidence of lymphocyst formation, their change in size with time, risk factors and correlation with symptoms. METHODS: This was a prospective observational study of 108 patients undergoing bilateral pelvic lymphadenectomy for gynecological cancer in our unit. We performed serial three-dimensional (3D) ultrasound assessment at 2 and 6 weeks and 3, 6, 9 and 12 months after surgery. Before each ultrasound assessment, symptoms were recorded and a physical examination was performed. RESULTS: Forty-eight (44.4%) patients had unilateral or bilateral lymphocysts detected during the follow-up period; 26 were on the left side, 16 were on the right side and six were bilateral. In 39 (81.2%) of the patients, the lymphocysts were first noted 2 weeks after the operation. In nine (18.8%) the lymphocysts persisted until 12 months after surgery. There was no association between lymphocyst formation and diagnosis, type of operation performed, surgeon, operative blood loss, adjuvant radiotherapy and number of lymph nodes removed. Four lymphocysts were detected by physical examination before the ultrasound diagnosis. There was no association between lymphocyst and symptoms, including pain over the abdomen, pelvis, thigh, legs or back, lymphedema, fever or symptoms of cystitis. Only one patient developed an infection of the lymphocyst, which required surgical intervention. CONCLUSION: Lymphocyst formation is common following bilateral pelvic lymphadenectomy. Most patients with lymphocysts are asymptomatic and the development of major complications is rare. PMID: 18548478 [PubMed - in process] _______________________________________________________________________________ _ Clin Physiol Funct Imaging. 2008 Sep;28(5):337-42. Epub 2008 Jun 5. Local tissue water assessed by tissue dielectric constant: anatomical site and depth dependence in women prior to breast cancer treatment-related surgery. Mayrovitz HN, Davey S, Shapiro E. College of Medical Sciences, Nova Southeastern University, Ft Lauderdale, FL 33328, USA. mayrovit@nova.edu Assessing local tissue water using tissue dielectric constant (TDC) values is useful to evaluate oedema/lymphoedema features and their change. Knowledge of anatomical site and tissue depth dependence of TDC values could extend this method's utility. Our goal was to compare TDC values obtained at anatomically paired sites and to investigate their depth dependence. In 22 women (12 awaiting surgery for breast cancer and 10 cancer-free control subjects), four sites (mid-forearm, mid- biceps, axilla and lateral thorax) on both body sides were measured with a 2.5-mm sampling depth probe. Also, at forearm, four different probes with sampling depths of 0.5, 1.5, 2.5 and 5 mm were used. TDC values range between 1 for zero water to 78.5 for 100% water. Site comparisons showed TDC values (mean+/-SD) to be largest at axilla (36.4+/-8.9), least at biceps (21.6+/-3.5) and not different between forearm and thorax (24.3+/-4.0 versus 24.8+/-5.0). Group comparisons showed slightly greater values in patients at forearm and biceps (P<0.05) but no group difference at other sites. Dominant-non-dominant side comparisons showed no significant difference in paired-TDC values in either group at any site. Forearm TDC values decreased with increasing depth from 36.4+/-4.8 at 0.5 mm to a minimum of 21.4+/-3.9 at 5.0 mm, with a sharp decline between 1.5 and 2.5 mm. The composite findings suggest that TDC measurements have the necessary features for usefully assessing oedema/lymphoedema and its change on limbs and at body sites not routinely amenable to assessment by other techniques. The depth dependence feature provides additional flexibility to investigate oedematous or lymphoedematous conditions. PMID: 18540873 [PubMed - in process] _______________________________________________________________________________ _ J Med Case Reports. 2008 Jun 24;2:216. Factitious lymphoedema as a psychiatric condition mimicking reflex sympathetic dystrophy: a case report. Nwaejike N, Archbold H, Wilson DS. Department of Vascular and Endovascular Surgery, Barts and The London NHS Trust, The Royal London Hospital, London, E1 1BB, UK. justnnamdi@aol.com. ABSTRACT: INTRODUCTION: Reflex sympathetic dystrophy can result in severe disability with only one in five patients able to fully resume prior activities. Therefore, it is important to diagnose this condition early and begin appropriate treatment. Factitious lymphoedema can mimic reflex sympathetic dystrophy and is caused by self-inflicted tourniquets, blows to the arm or repeated skin irritation. Patients with factitious lymphoedema have an underlying psychiatric disorder but usually present to emergency or orthopaedics departments. Factitious lymphoedema can then be misdiagnosed as reflex sympathetic dystrophy. The treatment for factitious lymphoedema is dealing with the underlying psychiatric condition. CASE PRESENTATION: We share our experience of treating a 33-year-old man, who presented with factitious lymphoedema, initially diagnosed as reflex sympathetic dystrophy. CONCLUSION: Awareness of this very similar differential diagnosis allows early appropriate treatment to be administered. PMID: 18577230 [PubMed - in process] PMCID: PMC2474643 _______________________________________________________________________________ _ FEBS Lett. 2008 Jul 23;582(17):2515-20. Epub 2008 Jun 18. Neostatin-7 regulates bFGF-induced corneal lymphangiogenesis. Kojima T, Azar DT, Chang JH. Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL 60612, USA. Neostatin-7, with an anti-angiogenic potential, is generated from the proteolytic action of matrix metalloproteinase-7 on collagen XVIII. We previously reported that neostatin-7 inhibited angiogenesis in vitro and in vivo. Here we demonstrate that neostatin-7/collagen XVIII may possess anti- lymphangiogenic activities by: (1) corneal micropellet implantation of neostatin-7 reduced bFGF-induced corneal lymphangiogenesis; (2) neostatin-7 bound to VEGF receptor-3 in vitro; and (3) enhanced corneal lymphangiogenesis and VEGF-C expression in collagen XVIII knockout mice in a corneal wounding model. Understanding the mechanism of neostatin-7/collagen XVIII on corneal lymphangiogenesis may provide therapeutic interventions to treat lymphangiogenesis-related disorders, such as lymphedema, transplantation rejection and cancers. Publication Types: Research Support, N.I.H., Extramural Research Support, Non-U.S. Gov't PMID: 18570894 [PubMed - indexed for MEDLINE] _______________________________________________________________________________ _ Wiad Lek. 2008;61(1-3):4-12. [Combined edema reducing therapy in the treatment of advanced lower limb lymphedema] [Article in Polish] Gabriel M, Sawlewicz P, Krüger A, Pawlaczyk K, Stanisiæ M, Majewski W. Kliniki Chirurgii Ogólnej i Naczyñ Uniwersytetu Medycznego w Poznaniu. mgabriel@pro.onet.pl Combined edema reducing therapy is a recognized method of lymphedema treatment. However such therapy can be difficult to implement from methodological and logistic point of view in cases of advanced forms of lymphedema. The aim of the study was the presentation and discussion of intensive phase of combined treatment in patient with advanced primary lymphedema. MATERIAL AND METHODS: Therapy was conducted on 19 patients (27 limbs) with edema reducing therapy program. Procedures were conducted daily for 4-6 weeks in out-patient and in-wards conditions. RESULTS: Intensive phase of treatment succeeded in 3870-15 330 ml edema reduction, consisting of 48-65% of initial status. Chronic leg ulcers were healed completely in 2 patients. Ten patients underwent minor adverse events (AE), such as superficial skin ulceration (n = 2), popliteal fossa skin maceration (n = 2), neuropathic foot pain (n = 3) and skin scratches (n = 3). Modification of the treatment allowed the complete healing of AEs within 2-7 days, but it produced significant delay in achievement of desired therapeutic result, In 2 cases it prolonged hospital stay for 7 days. CONCLUSIONS: 1. Combined edema reducing therapy is very efficient form of treatment in advanced primary lymphedema. 2. Intensive, 4-6 week, phase of the treatment allows 3.8 to 15.3 1 edema reduction. 3. In our opinion this phase should be conducted only in specialized centers for proper final results achievement with adverse events minimization. 4. The main point of the therapy is a combination of appropriate forms of available treatment. Publication Types: English Abstract PMID: 18717036 [PubMed - in process] _______________________________________________________________________________ _ Lymphology. 2008 Jun;41(2):93-5. Humanitarian rescue medical action for patient with advanced lower extremity lymphedema. Chen HC, Salgado CJ, Mardini S, Feng GM, Li TS. E-Da Hospital/I-Shou University, Department of Plastic Surgery, Yan-Chau Shiang, Kaohsiung County, Taiwan. salgado_plastics@hotmail.com No clear data exists regarding the initiating process of medial care delivery in cases of humanitarian rescue for advanced and debilitating patient conditions. We report on the delivery of care from a hospital located in a rural area in Southern Taiwan to a desperate patient from a country across the world in Lima, Peru. The patient is a 45-year old woman with unilateral severe, progressive primary lymphedema of 26 years who was scheduled to undergo a high femoral amputation for infections, lymphatic leak, inability to ambulate, and symptomatic cardiomegaly. All arrangements for care, including dental restoration, were made by our hospital in collaboration with the government of Peru. Upon multi- departmental consultation, an 8-hour Charles procedure was performed removing 47 kg of lymphedematous thigh and leg tissue. Eleven months postoperatively the patient is healed and ambulating without assistance. Her weight dropped from 120 to 73 kg. This case of humanitarian action demonstrates intense collaboration and coordination between two governments with dialogue, diplomatic success, a lymphedema surgical feat, and ultimately a successful outcome for the patient. Publication Types: Case Reports PMID: 18720917 [PubMed - indexed for MEDLINE] _______________________________________________________________________________ _ Lymphology. 2008 Jun;41(2):87-92. Localized tissue water changes accompanying one manual lymphatic drainage (MLD) therapy session assessed by changes in tissue dielectric constant inpatients with lower extremity lymphedema. Mayrovitz HN, Davey S, Shapiro E. College of Medical Sciences, Nova Southeastern University, Ft. Lauderdale, Florida 33328, USA. mayrovit@nova.edu Previous reports described the utility of assessing local tissue water via tissue dielectric constant (TDC) measurements. Our goal was to determine the suitability of this method to evaluate lymphedema changes. For this purpose, we measured changes in TDC produced by one MLD treatment in 27 legs of 18 patients with lower extremity lymphedema. TDC values were measured to a depth of 2.5 mm at the greatest leg swelling site before and after one MLD treatment. Girth at the target site was measured with a calibrated tape measure. TDC values, which range from 1 for zero water to 78.5 for all water within the sampled volume, were measured four times and the average used to estimate local changes. Results showed that in every case the posttreatment TDC was reduced from its pretreatment value with percentage reductions (mean SD) of -9.8 +/- 5.64% (p < 0.0001). Girth changes were smaller being -1.5 +/- 1.93% (p < 0.01). We conclude that since TDC measurements reflect changes to a depth of about 2.5 mm whereas girth measurements reflect conditions of the entire cross-section, TDC assessment may be more sensitive to localized lymphedema changes. This finding suggests that TDC measurements are useful as complementary and perhaps as independent assessment methods of edema/lymphedema and treatment-related changes. PMID: 18720916 [PubMed - indexed for MEDLINE] _______________________________________________________________________________ _ Ann Dermatol Venereol. 2008 Jun-Jul;135(6-7):488-91. Epub 2008 Apr 14. [Cutaneous angiosarcoma of the leg without lymphoedema] [Article in French] Le Corre Y, Avenel-Audran M, Croué A, Steff M, Verret JL. Service de dermatologie, faculté de médecine, université d'Angers, CHU d'Angers, 4, rue Larrey, 49933 Angers cedex 09, France. BACKGROUND: Cutaneous angiosarcoma is a rare aggressive vascular neoplasm with a poor prognosis, seen chiefly in elderly subjects and usually on the scalp or face. The present case is original because of its localization on the leg without any chronic lymphoedema and because of the long survival period. The treatment modalities are discussed. CASE REPORT: An 87-year-old woman presented with a rapidly growing large deep-purple ulcerated tumour on the anterior aspect of the leg. In addition, two nodules with a similar aspect appeared on the outer surface of the foot. Histological examination showed vascular channels lined with atypical cells consistent with a diagnosis of angiosarcoma. Computed tomography revealed no metastases. Amputation was performed at the thigh and there was no recurrence 30 months later. DISCUSSION: The leg is a rare site of cutaneous angiosarcoma. Treatment usually consists of surgical excision with wide margins followed by radiotherapy, but in some cases amputation is unavoidable. Publication Types: English Abstract PMID: 18598799 [PubMed - in process] ________________________________________________________________ Int J Surg Pathol. 2008 May 21. [Epub ahead of print] Metastatic Angiosarcoma in an Ileal Conduit: An Unusual Presentation. Avramut M, Parwani AV. The authors in this study describe the case of a patient with a history of multiple malignancies who underwent total cystectomy with ileal loop urinary diversion and presented with a lower extremity angiosarcoma on the background of lymphedema a decade later. Shortly thereafter, she was diagnosed with metastatic ileal conduit angiosarcoma. The authors state that to their knowledge, this is the first case of ileal conduit angiosarcoma reported in the English literature. ------------------------------------------------------------------------------------------- Sarcoma. 2008;2008:459386 Frequency of certain established risk factors in soft tissue sarcomas in adults: a prospective descriptive study of 658 cases. Penel N, Grosjean J, Robin YM, Vanseymortier L, Clisant S, Adenis A. Département de Cancérologie Générale, Centre Oscar Lambret, 59020 Lille, France. Soft tissue sarcomas are rare tumours with infrequent identified aetiological factors. Several genetic syndromes as well as previous radiation therapy and/or chronic lymphoedema have been suspected to predispose to some soft tissue sarcomas. Between January 1997 and September 2005, we carried out a prospective descriptive study to estimate the frequency of some particular etiological factors among 658 patients with soft tissue sarcomas. Sarcomas associated with a clinically identified genetic disease represent 2.8% out of all cases (95%CI: 1.5-3.8%). Most of these cases (14/19) are related to Recklinghausen neurofibromatosis. Radiation-induced sarcomas represent 3.3% out of all cases (95% CI: 1.7-5.1%). Most of these cases (9/22) are related to prior breast cancer treatment. We had observed only 1 case of Stewart-Treves syndrome. Liposarcoma, the most frequent histological subtype observed, is not associated with any particular aetiological entity. Finally, most of the adult soft tissue sarcomas are not related to any classical clinically identified genetic disease or previous radiation therapy and/or chronic lymphoedema risk factors. Frequency of underlying genetic syndrome which may predispose to soft tissue sarcomas could be higher than previously reported. PMID: 18497869 [PubMed - in process] PMCID: PMC2386887 http://www.ncbi.nlm.nih.gov/pubmed/18497869?dopt=Abstract ---------------------------------------------------------------------------------------------------- Minerva Med. 2008 Jun;99(3):341-5. Right leg swelling as primary presentation of metastatic Merkel cell carcinoma. Noto R, Giaquinta A, Alessandria I, Soma P, Latteri S, Grasso G, Fraggetta F. Istituto di Medicina Interna, Università degli Studi di Catania, Azienda Ospedaliera Cannizzaro, Catania, Italia. noto@unict.it Merkel cell carcinoma (MCC) is a rare malignant cutaneous neuroendocrine tumour with an aggressive behaviour and frequent regional lymph node and distant metastases. It mostly occurs in old patients and the commonest sites are the skin of the head, neck and the extremities. Typically, the primary tumour presents as a fast-growing, painless, reddish nodule with an iceberg-like effect, broadening in the depth. Although the pathogenesis of MCC remains largely unknown, ultraviolet radiation and immunosuppression are likely to play a significant pathogenetic role. The authors describe an unusual case of MCC clinically presenting as lymphedema on the right leg due to an inguinal lymphonodal metastasis. Although extensive investigations were performed the authors were unable to discover the cutaneous primary tumor. The authors examine the etiopathogenesis and hypothesis of this rare tumour and describe the clinical differential diagnosis. They suggest that clinical features together with imaging studies and morphological and immuno-histochemical findings are important for the correct diagnosis. Am J Dermatopathol. 2008 Jun;30(3):265-8.Related Articles, Links An "anaplastic" Kaposi's sarcoma mimicking a Stewart-Treves syndrome. A case report and a review of literature. Salameire D, Templier I, Charles J, Pinel N, Morand P, Leccia MT, Lantuejoul S. Pôle de biologie-Département d'Anatomie et Cytologie Pathologiques, CHU Grenoble, France. DSalameire@chu-grenoble.fr Cutaneous angiosarcoma (AGS) developing in a lymphedematous arm, after lymphadenectomy in the context of breast cancer, is the definition of the classical Stewart-Treves syndrome. Like AGS, many tumors such as Kaposi's sarcoma (KS) could develop in chronic lymphedema. We describe the case of a 50-year-old woman who presented with several nodules on the left lymphedematous arm evocative of a Stewart-Treves syndrome, 2 years after a left mastectomy and a homolateral lymphadenectomy. The histological examination revealed an atypical vascular proliferation suggesting AGS, but endothelial atypical cells nuclei were strongly stained by herpes human virus 8 antibody. The final diagnosis was an "anaplastic" KS mimicking a Stewart-Treves syndrome. The total regression of the lesion was obtained by elastic contention and intradermic liposomal doxorubicin. "Anaplastic" KS is a rare histological form of nodular KS, which mimics a cutaneous AGS but classically expresses herpes human virus 8. It is essential to know about this entity, particularly in a lymphedematous arm, to avoid aggressive treatment such as amputation. Publication Types: Case Reports PMID: 18496429 [PubMed - indexed for MEDLINE] http://www.ncbi.nlm.nih.gov/pubmed/18496429?dopt=Abstract --------------------------------------------------------------------------------------- PMID: 18497730 [PubMed - in process]http://www.ncbi.nlm.nih.gov/pubmed/18497730? dopt=Abstract ----------------------------------------------------------------------------------------------------- J Clin Gastroenterol. 2008 Jul;42(6):715-9.Related Articles, Links Congenital lymphedema-lymphangiectasia associated with scrotal angiokeratoma (Fordyce Type) and hearing impairment. Pavone P, Lucenti C, Fraggetta F, Micali G, Incorpora G, Ruggieri M. Department of Paediatrics, University of Catania, Catania, Italy. Congenital lymphangiectasia-lymphedema is a rare disorder that presents with edema of the lower half of the body, the face, hands, and scrotum, or with protein-losing enteropathy owing to structural anomalies in the endothelium of the lymphatic system. We describe a biopsy-proven case of severe lymphangiectasia-lymphedema in a 16-year-old boy who was born to consanguineous parents and who, in addition, had mild (20 to 40 dB), early onset, sensorineural deafness and skin abnormalities, consisting of angiokeratomas of the face, hands, and feet, and also a large, localized angiokeratoma of the scrotum and the penis (Fordyce type). Both of the proband's parents had profound (>80 dB), congenital, mixed conductive/sensorineural, nonsyndromic deafness to low-mid frequencies. To the best of our knowledge, this constellation of lymphatic, skin, hearing, and systemic abnormalities seen in the proband has not been previously reported. PMID: 18496391 [PubMed - in process] http://www.ncbi.nlm.nih.gov/pubmed/18496391?dopt=Abstract --------------------------------------------------------------------------------------------- Cancer Nurs. 2008 Jul-Aug;31(4):302-9; quiz 310-1. Postlymphadenectomy complications and quality of life among breast cancer patients in Brazil. Paim CR, de Paula Lima ED, Fu MR, de Paula Lima A, Cassali GD. Federal University of Minas Gerais, Brazil This descriptive, cross-sectional, correlational study with a convenience sample of 96 women treated for breast cancer at an outpatient service in Brazil was designed to investigate postlymphadenectomy complications after axillary lymph node dissection (ALND) and sentinel lymph node biopsy and explore the associative relationships between the complications and quality of life. Clinical evaluations using perimetry, goniometry, and muscle strength test were used to evaluate the complications. Pain and quality of life were assessed by the Short-Form McGill Pain Questionnaire and the Functional Assessment of Cancer Therapy-Breast. All participants had at least one complication. Incidence was higher for pain (57%), impaired shoulder strength (57%), and fibrosis (54%), followed by impaired shoulder range of motion (46%) and lymphedema (17%). The incidence of impaired shoulder flexion (P = .01) and lymphedema (P = .002) was higher in ALND group. Winged scapula (8.4%) only occurred in the ALND group. Quality of life was significantly correlated with pain (r = -0.53, P = .000) and impaired shoulder strength in flexion (r = 0.4; P = .000) and abduction (r = -0.5, P = .000). Future studies are needed to prospectively investigate the onset of the complications and identify appropriate interventions to promote quality of life in women treated for breast cancer. PMID: 18600117 [PubMed - in process] __________________________________________________________________ Ann Dermatol Venereol. 2008 Jun-Jul;135(6-7):488-91. Epub 2008 Apr 14.[Cutaneous angiosarcoma of the leg without lymphoedema] [Article in French] Le Corre Y, Avenel-Audran M, Croué A, Steff M, Verret JL.Service de dermatologie, faculté de médecine, université d'Angers, CHU d'Angers, 4, rue Larrey, 49933 Angers cedex 09, France. BACKGROUND: Cutaneous angiosarcoma is a rare aggressive vascular neoplasm with a poor prognosis, seen chiefly in elderly subjects and usually on the scalp or face. The present case is original because of its localization on the leg without any chronic lymphoedema and because of the long survival period. The treatment modalities are discussed. CASE REPORT: An 87-year-old woman presented with a rapidly growing large deep-purple ulcerated tumour on the anterior aspect of the leg. In addition, two nodules with a similar aspect appeared on the outer surface of the foot. Histological examination showed vascular channels lined with atypical cells consistent with a diagnosis of angiosarcoma. Computed tomography revealed no metastases. Amputation was performed at the thigh and there was no recurrence 30 months later. DISCUSSION: The leg is a rare site of cutaneous angiosarcoma. Treatment usually consists of surgical excision with wide margins followed by radiotherapy, but in some cases amputation is unavoidable. Publication Types: English Abstract PMID: 18598799 [PubMed - in process] __________________________________________________________________ Dermatol Online J. 2008 Jul 15;14(7):20.Foreign body granuloma formation secondary to silicone injection. Schwartzfarb EM, Hametti JM, Romanelli P, Ricotti C. Injectable silicone has been used extensively over the last 40 years for soft tissue augmentation. Although considered biologically inert, this material has been implicated in a variety of adverse reactions including granulomas, disfiguring nodules, and lymphedema, sometimes with latent periods of decades. Often these complications are a result of the use of industrial grade products injected by unlicensed or unskilled practitioners. Here we report a case of foreign body granuloma in the thigh secondary to silicone injection in the buttocks. Initially the patient did not disclose a cosmetic contouring procedure administered by a nonprofessional nine months earlier, making diagnosis difficult. We remind clinicians to include foreign body granulomas in the differential diagnosis of apparent cellulitis and to question patients about the use of injectable fillers. Publication Types: LetterPMID: 18718204 [PubMed - in process] __________________________________________________________________ Am J Physiol Lung Cell Mol Physiol. 2008 Jul 25. [Epub ahead of print]T1{alpha}/PODOPLANIN IS ESSENTIAL FOR CAPILLARY MORPHOGENESIS IN LYMPHATIC ENDOTHELIAL CELLS. Navarro A, Perez RE, Rezaiekhaligh M, Mabry SM, Ekekezie II. Children's Mercy Hospitals and Clinics/University of Missouri - Kansas City School of Medicine, Kansas City, Missouri. The lymphatic vasculature functions to maintain tissue perfusion homeostasis. Defects in its formation or disruption of the vessels result in lymphedema, the effective treatment of which is hampered by limited understanding of factors regulating lymph vessel formation. Mice lacking T1alpha/podoplanin, a lymphatic endothelial cell trans-membrane protein, have malformed lymphatic vasculature with lymphedema at birth, but the molecular mechanism for this phenotype is unknown. Here we show, using primary human lung microvascular lymphatic endothelial cells (HMVEC-LLy), that small interfering RNA (siRNA) mediated silence of podoplanin gene expression has the dramatic effect of blocking capillary tube formation in Matrigel(TM). In addition, localization of phosphorylated ezrin/radixin/moesin (ERM) proteins to plasma membrane extensions, an early event in the capillary morphogenic program in lymphatic endothelial cells, is impaired. We find that cells with decreased podoplanin expression fail to properly activate the small GTPase RhoA early (by 30 minutes) after plating on Matrigel(TM), and Rac1 shows a delay in its activation. Further indication podoplanin action is linked to RhoA activation is that use of a cell permeable inhibitor of RhoA inhibited lymphatic endothelial capillary tube formation in the same manner as did podoplanin gene silencing, which was not mimicked by treatment with a Rac1 inhibitor. These data clearly demonstrate that early activation of RhoA in the lymphangiogenic process, which is required for the successful establishment of the capillary network, is dependent on podoplanin expression. To our knowledge, this is the first time that a mechanism has been suggested to explain the role of podoplanin in lymphangiogenesis. Key words: Lymphedema, lymphatics, GTPases, RhoA, Rac1, Matrigel(TM). PMID: 18658274 [PubMed - as supplied by publisher] __________________________________________________________________ Ann Surg Oncol. 2008 Oct;15(10):2847-55. Epub 2008 Jul 23.The outcome of laparoscopic radical hysterectomy and lymphadenectomy for cervical cancer: a prospective analysis of 295 patients. Chen Y, Xu H, Li Y, Wang D, Li J, Yuan J, Liang Z. Department of Obstetrics and Gynecology, Southwest Hospital, Third Military Medical University, Chongqing, 400038, P.R. China. OBJECTIVES: Cervical carcinoma is likely to become one of the most important indications for laparoscopic radical surgery. The laparoscopic technique combines the benefits of a minimally invasive approach with established surgical principles. In our institution, the laparoscopic radical hysterectomy and transperitoneal approach for lymphadenectomy have become the standard techniques for invasive cervical cancer. We report the indications, techniques, results, and oncological outcome in a single center experience. METHODS: Between February 2001 and June 2007 we performed laparoscopic radical hysterectomies for cervical cancer in 295 patients. Their initial techniques, operation data, complications, postoperative course, oncological outcome, and survival were evaluated. RESULTS: Out of 295 procedures, 290 were successful. Para-aortic lymphadenectomy was performed in 156 patients (52.9%), and pelvic lymphadenectomy was performed in all 295 patients. The median blood loss was 230 mL (range, 50-1200 mL). The mean operation time was 162 min (range, 110-350), which included the learning curves of 3 surgeons. In 5 cases (1.7%), conversion to open surgery was necessary due to bleeding (3 cases), bowel injury (1 case), and hypercapnia (1 case). Other major intraoperative injuries occurred in 12 patients (4.1%). Positive lymph nodes were detected in 80 cases (27.1%), lymphovascular space invasion in 54 cases (18.3%), and surgical margins were negative for tumor in all patients. The mean hospital stay was 10.3 days. Postoperative complications occurred in 10.8% patients, ureterovaginal fistula in 5 cases, vesicovaginal fistula in 4, ureterostenosis in 3 cases, deep venous thrombosis in 9 cases, lymphocyst in 4 cases, lymphedema in 5 cases, and 1 case with trocar insertion site metastasis. Other medical problems included 47 cases (15.9%) of bladder dysfunction and 62 cases (21.0%) of rectum dysfunction or constipation. The median follow-up was 36.45 months (range, 8-76 months). Recurrences or metastasis occurred in 48 patients (16.3%). Of these patients, 43 (14.6%) have died of their disease, and 5 (1.7%) are alive with disease. The overall disease-free survival was 95.2% for Ia, 96.2% for Ib, 84.5% for IIa, 79.4% for IIb, 66.7% for IIIa, and 60.0% for IIIb. CONCLUSION: Laparoscopic radical hysterectomy is a routine, effective treatment for patients with Ia2-IIb cervical carcinoma. With more experience it is envisaged that IIb stage patients can be managed safely offering all the benefits of minimal surgery to the patients. Although no long-term follow-up is available, our follow-up data for up to 76 months confirm the effectiveness of laparoscopic radical hysterectomy in terms of surgical principles and oncological outcome. Publication Types: Research Support, Non-U.S. Gov't PMID: 18649105 [PubMed - in process] __________________________________________________________________ J Clin Oncol. 2008 Jul 20;26(21):3536-42.Lymphedema after breast cancer: incidence, risk factors, and effect on upper body function.Hayes SC, Janda M, Cornish B, Battistutta D, Newman B.Institute of Health and Biomedical Innovation, School of Public Health, Queensland University of Technology, Kelvin Grove, Queensland, Australia. sc.hayes@qut.edu.au PURPOSE: Secondary lymphedema is associated with adverse physical and psychosocial consequences among women with breast cancer (BC). This article describes the prevalence and incidence of lymphedema between 6 and 18 months after BC treatment; personal, treatment, and behavioral correlates of lymphedema status; and the presence of other upper-body symptoms (UBS) and function (UBF). PATIENTS AND METHODS: A population-based sample of Australian women (n = 287) with recently diagnosed, invasive BC were evaluated on five occasions using bioimpedance spectroscopy. Lymphedema was diagnosed when the ratio of impedance values, comparing treated and untreated sides, was three standard deviations more than normative data. UBF was assessed using the validated Disability of the Arm, Shoulder, and Hand questionnaire. RESULTS: From 6 to 18 months after surgery, 33% (n = 62) of the sample were classified as having lymphedema; of these, 40% had long-term lymphedema. Although older age, more extensive surgery or axillary node dissection, and experiencing one or more treatment-related complication(s) or symptom(s) at baseline were associated with increased odds, lower socioeconomic status, having a partner, greater child care responsibilities, being treated on the dominant side, participation in regular activity, and having good UBF were associated with decreased odds of lymphedema. Not surprisingly, lymphedema leads to reduced UBF; however, BC survivors report high prevalences of other UBS (34% to 62%), irrespective of their lymphedema status. CONCLUSION: Lymphedema is a public health issue deserving greater attention. More systematic surveillance for earlier detection and the potential benefits of physical activity to prevent lymphedema and mitigate symptoms warrant further clinical integration and research. Publication Types: Research Support, Non-U.S. Gov'tPMID: 18640935 [PubMed - indexed for MEDLINE] __________________________________________________________________ J Clin Oncol. 2008 Jul 20;26(21):3530-5.Comment in:J Clin Oncol. 2008 Jul 20;26(21):3483-4. Impact of immediate versus delayed axillary node dissection on surgical outcomes in breast cancer patients with positive sentinel nodes: results from American College of Surgeons Oncology Group Trials Z0010 and Z0011. Olson JA Jr, McCall LM, Beitsch P, Whitworth PW, Reintgen DS, Blumencranz PW, Leitch AM, Saha S, Hunt KK, Giuliano AE; American College of Surgeons Oncology Group Trials Z0010 and Z0011. Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA. jaomd@duke. eduPURPOSE: Patients with breast cancer metastasis to the sentinel lymph nodes (SLNs) generally undergo completion axillary lymph node dissection (cALND), either concurrently with SLN biopsy or at a second procedure. The impact of the timing of cALND on pathologic results and complications in these patients has not been examined. PATIENTS AND METHODS: We examined outcomes from SLN-positive patients in American College of Surgeons Oncology Group (ACOSOG) trials Z0010 and Z0011. Pathologic data examined included primary tumor characteristics, total number of SLNs recovered, positive SLN(s) and non-SLN(s) identified. Complications assessed included axillary seroma, paresthesia, arm morbidity and range of motion, and lymphedema. RESULTS: A total of 1,003 assessable patients with SLN metastasis had immediate (n = 425) or delayed (n = 578) cALND. The median number of SLNs and axillary LNs removed were the same between groups. Patients who had immediate cALND more often had larger tumors, SLN metastasis identified intraoperatively, two or more positive SLNs, and higher pathologic N stage. Axillary paresthesia, seroma, and impaired extremity range of motion were more common in the immediate group during the early postoperative period, but not at later time points. There was no difference in lymphedema at any time point. CONCLUSION: In ACOSOG trials Z0010 and Z0011, LN recovery and long-term complications were similar after either delayed or immediate cALND for patients with metastasis to SLNs. Patients who undergo immediate cALND experience more short-term morbidity. With respect to staging and complications, there is no clear detriment for patients with a positive SLN who undergo a second procedure for cALND.Publication Types: Multicenter Study Research Support, N.I.H., ExtramuralPMID: 18640934 [PubMed - indexed for MEDLINE] __________________________________________________________________ Eur J Cancer Care (Engl). 2008 Jul 7. [Epub ahead of print]Effects of complex decongestive physiotherapy on the oedema and the quality of life of lower unilateral lymphoedema following treatment for gynecological cancer.Kim SJ, Park YD. Department of Physical Therapy, Youngdong University, Chungbuk, Republic of Korea. There is increasing interest in the health-related quality of life (QOL) of patients with chronic lymphoedema. The purpose of the present study was to ascertain whether or not complex decongestive physiotherapy (CDP) for 57 gynecological cancer patients with unilateral lymphedema results in a measurable change in the oedema and QOL, and % excess volume correlated with change in QOL. % excess volume was significantly (P < 0.05) decreased after CDP. The QOL scores were significantly (P < 0.05) higher than the scores at baseline, indicating an improvement in the QOL. The change in % excess volume was associated with a change in physical functioning, social functioning, role-physical, bodily pain and general health at baseline and 1 month (P < 0.05). This study suggests that significant improvements are made in the QOL of gynecological cancer patients with unilateral lymphoedema after CDP, which is necessarily correlated with limb reduction. PMID: 18637114 [PubMed - as supplied by publisher] __________________________________________________________________ J Altern Complement Med. 2008 Jul;14(6):769-76.Evidence-based approaches for the Ayurvedic traditional herbal formulations: toward an Ayurvedic CONSORT model.Narahari SR, Ryan TJ, Aggithaya MG, Bose KS, Prasanna KS. Institute of Applied Dermatology, Kasaragod, Kerala, India. srnarahari@satyam.net.in This paper considers the problem of evaluating multimodal integrative medicine treatments for complex pathologic conditions. The example is given of evaluation of highly successful treatments of lymphedema using Ayurvedic and Yoga medicine practices together with modern medicine. For a framework to evaluate such a complex intervention, we base our proposal on Consolidated Standards of Reporting Trials (CONSORT) guidelines.Publication Types: Research Support, Non-U.S. Gov'tPMID: 18684081 [PubMed - in process] __________________________________________________________________ Int J Surg Pathol. 2008 Jul 8. [Epub ahead of print] Massive Localized Lymphedema With Unusual Presentations : Report of Two Cases and Review of the Literature. Bogusz AM, Hussey SM, Kapur P, Peng Y, Gokaslan ST. Massive localized lymphedema is a benign soft tissue lesion that usually presents as a large mass in morbidly obese adults. The diagnosis may be challenging as it can mimic other lesions, including well- differentiated liposarcoma. We report 2 cases of massive localized lymphedema with unusual presentation. The first case is a recurrent massive localized lymphedema in the right thigh of a 40-year- old morbidly obese woman. In addition to typical massive localized lymphedema features such as prominent edema and vascular proliferation in the adipose tissue, we observed prominent and abundant multinucleated stromal floret-like giant cells, arborizing network of capillaries, and areas of hyalinized collagen. Our second case is in a rare location (scrotum extending into penile soft tissue) in an overweight 55-year-old male. This lesion exhibits striking smooth muscle hyperplasia. Lack of staining by antibodies against murine double minute 2 protein and cyclin dependent kinase 4 and absence of high mobility group AT- hook 2 transcription factor rearrangement by fluorescence in situ hybridization support our diagnosis of massive localized lymphedema in both cases. PMID: 18611926 [PubMed - as supplied by publisher] -------------------------------------------------------------------------------- Int J Surg Pathol. 2008 Jul 8. [Epub ahead of print]Massive Localized Lymphedema With Unusual Presentations : Report of Two Cases and Review of the Literature.Bogusz AM, Hussey SM, Kapur P, Peng Y, Gokaslan ST. Massive localized lymphedema is a benign soft tissue lesion that usually presents as a large mass in morbidly obese adults. The diagnosis may be challenging as it can mimic other lesions, including well- differentiated liposarcoma. We report 2 cases of massive localized lymphedema with unusual presentation. The first case is a recurrent massive localized lymphedema in the right thigh of a 40-year- old morbidly obese woman. In addition to typical massive localized lymphedema features such as prominent edema and vascular proliferation in the adipose tissue, we observed prominent and abundant multinucleated stromal floret-like giant cells, arborizing network of capillaries, and areas of hyalinized collagen. Our second case is in a rare location (scrotum extending into penile soft tissue) in an overweight 55-year-old male. This lesion exhibits striking smooth muscle hyperplasia. Lack of staining by antibodies against murine double minute 2 protein and cyclin dependent kinase 4 and absence of high mobility group AT- hook 2 transcription factor rearrangement by fluorescence in situ hybridization support our diagnosis of massive localized lymphedema in both cases PMID: 18611926 [PubMed - as supplied by publisher] __________________________________________________________________ J Mal Vasc. 2008 Jul 3. [Epub ahead of print] [Cystic lymphangioma: An unusual cause of lower limb lymphedema.] [Article in French] Hadj-Henni A, Ladan-Marcus V, Javerliat I, Bouhzam N, Fouilhe L, Marcus C, Long A.Unité de médecine vasculaire, hôpital Robert-Debré, CHU de Reims, rue du Professeur-Kochman, 51100 Reims, France. We report an unusual cause of unilateral lymphedema of the right limb rapidly increasing in a young woman. Ultrasonography ruled out the diagnosis of iliac deep venous thrombosis or extrinsic compression: the B mode scan revealed a mass located below the aortic bifurcation and along the iliac vessels, without any compressive effect. The lesion was heterogeneous associating both tissular and cystic aspects. The lower limb lymphoscintigraphy showed an interruption of the colloid circulation at the right iliac level. Computed tomography did not give any additional information. Magnetic resonance imaging before then after gadolinium showed typical aspects of cystic lymphangioma and confirmed the ultrasonography hypothesis. Considering that this tumor is benign, that surgery would be difficult because of the anatomic situation of the mass, and that post-operative involution of the edema is uncertain, the treatment was based on compressive stockings and regular follow up. PMID: 18602782 [PubMed - as supplied by publisher] __________________________________________________________________ Handchir Mikrochir Plast Chir. 2008 Aug;40(4):272-8. Epub 2008 Jul 16.[Genital Elephantiasis: Reconstructive Treatment of Penoscrotal Lymphoedema with a Myocutaneous M. gracilis Flap. Experiences from a District Hospital in Ethiopia.] Article in German]Prica S, Donati OF, Schaefer DJ, Peltzer J. Chirurgie, Hôpital du Jura, Delémont, Schweiz.BACKGROUND: Genital elephantiasis is an illness leading to serious functional and aesthetic as well as psychosocial impairment. Since the 19th century there have been articles describing methods for surgical ablative treatment of penoscrotal lymphoedema. However, most of these methods ignore the creation a new drainage for the lymph. We now describe a new technique using a myocutaneous M. gracilis muscle flap for the reconstruction of the soft tissue damage resulting from radical excision, thus ensuring drainage of the lymph into the deep muscle compartment of the thigh. PATIENTS AND METHOD: In the District Hospital "Mettu-Karl Hospital" in the Ethiopian rain forest region of Illubabor, during a period of 6 months the described surgical procedure was applied to 9 patients suffering from severe forms of this grotesquely disfiguring disease. Two patients presented with combined penoscrotal oedema, while the other 7 patients were suffering from isolated scrotal lymphoedema alone. All patients benefited from reconstruction with a myocutaneous M. gracilis muscle flap after radical excision of the affected tissue. All patients were evaluated after 3 and 12 months postoperatively in the presence of a translator. RESULTS: All nine patients showed a functionally and aesthetically satisfying result after 3 months without postoperative occurrence of infection. The evaluation 12 months postoperatively showed no recurrence of genitoscrotal lymphoedema. All patients reported on having regained normal ability for sexual intercourse and no occurrence of urinary tract infections since the operation. Concerning fertility, no statements could be made. A significant improvement in the quality of life was observed by the regained ability to walk and work and consequently the reintegration of the patients into their socio-economic environment. CONCLUSION: Radical excision of the affected tissue followed by transferring a functioning lymphatic drainage into the deep muscle compartment of the ipsilateral thigh using a proximally based myocutaneous gracilis muscle flap treats genital lymphoedema without recurrence. Satisfying aesthetic and functional results are achieved. The described surgical technique is still successfully being performed by two Ethiopian surgeons trained in this procedure.Publication Types:English AbstractPMID: 18633886 [PubMed - in process ]__________________________________________________________________ Handchir Mikrochir Plast Chir. 2008 Aug;40(4):272-8. Epub 2008 Jul 16.[Genital Elephantiasis: Reconstructive Treatment of Penoscrotal Lymphoedema with a Myocutaneous M. gracilis Flap. Experiences from a District Hospital in Ethiopia.][Article in German] Prica S, Donati OF, Schaefer DJ, Peltzer J. Chirurgie, Hôpital du Jura, Delémont, Schweiz. BACKGROUND: Genital elephantiasis is an illness leading to serious functional and aesthetic as well as psychosocial impairment. Since the 19th century there have been articles describing methods for surgical ablative treatment of penoscrotal lymphoedema. However, most of these methods ignore the creation a new drainage for the lymph. We now describe a new technique using a myocutaneous M. gracilis muscle flap for the reconstruction of the soft tissue damage resulting from radical excision, thus ensuring drainage of the lymph into the deep muscle compartment of the thigh. PATIENTS AND METHOD: In the District Hospital "Mettu-Karl Hospital" in the Ethiopian rain forest region of Illubabor, during a period of 6 months the described surgical procedure was applied to 9 patients suffering from severe forms of this grotesquely disfiguring disease. Two patients presented with combined penoscrotal oedema, while the other 7 patients were suffering from isolated scrotal lymphoedema alone. All patients benefited from reconstruction with a myocutaneous M. gracilis muscle flap after radical excision of the affected tissue. All patients were evaluated after 3 and 12 months postoperatively in the presence of a translator. RESULTS: All nine patients showed a functionally and aesthetically satisfying result after 3 months without postoperative occurrence of infection. The evaluation 12 months postoperatively showed no recurrence of genitoscrotal lymphoedema. All patients reported on having regained normal ability for sexual intercourse and no occurrence of urinary tract infections since the operation. Concerning fertility, no statements could be made. A significant improvement in the quality of life was observed by the regained ability to walk and work and consequently the reintegration of the patients into their socio- economic environment. CONCLUSION: Radical excision of the affected tissue followed by transferring a functioning lymphatic drainage into the deep muscle compartment of the ipsilateral thigh using a proximally based myocutaneous gracilis muscle flap treats genital lymphoedema without recurrence. Satisfying aesthetic and functional results are achieved. The described surgical technique is still successfully being performed by two Ethiopian surgeons trained in this procedure.Publication Types: English Abstract PMID: 18633886 [PubMed - in process] __________________________________________________________________ Clin Exp Dermatol. 2008 Jul 4. [Epub ahead of print]Persistent lymphoedema in Morbihan disease: formation of perilymphatic epithelioid cell granulomas as a possible pathogenesis. Nagasaka T, Koyama T, Matsumura K, Chen KR. Department of Dermatology, Saiseikai Central Hospital, Tokyo, Japan. Morbihan disease is a rare complication of rosacea, characterized by persistent lymphoedema on the upper half of the face, occurring during the chronic clinical course of rosacea. This refractory condition has been also designated as 'rosacea lymphoedema' and 'solid persistent facial oedema of rosacea'. We report a patient with Morbihan disease showing persistent lymphoedema on the upper half of the face accompanied by unique histological findings of striking dermal dilated lymphatics and damage of the lymphatics at the site of the adjacent epithelioid cell granulomas, with histiocytes bulging into the lymphatic lumen. The marked epithelioid cell granulomas forming around dermal lymphatic vessels with subsequent lymphatic damage and luminal obstruction by histiocytic infiltration may account for the development of lymphoedema in this patient. PMID: 18627384 [PubMed - as supplied by publisher] __________________________________________________________________ AUGUST 2008 LYMPHEDEMA ABSTRASTS N Engl J Med. 2008 Aug 28;359(9):950.Images in clinical medicine. The Stewart-Treves syndrome. Pincus LB, Fox LP. University of California at San Francisco, San Francisco, CA 94143, USA.Publication Types: Case ReportsPMID: 18753651 [PubMed - indexed for MEDLINE ]____________________________________________________________________ Clin Oncol (R Coll Radiol). 2008 Aug 21. [Epub ahead of print]Selective Axillary Node Sampling and Radiotherapy to the Axilla in the Management of Breast Cancer. Tanguay JS, Ford DR, Sadler G, Buckley L, Uppal H, Cross J, Holmes N, Fortes Mayer K, Fernando I. University Hospital Birmingham, Birmingham, UK; Walsall Manor Hospital, Walsall, West Midlands, UK.AIMS: Axillary treatment for patients with early-stage breast cancer can be associated with considerable morbidity. Techniques, such as axillary node sampling (ANS) and, more recently, sentinel node biopsy, in combination with radiotherapy have the potential to reduce toxicity. A retrospective review of axillary treatment in patients with early-stage breast cancer treated at our institution between 1997 and 2003 was carried out to assess the outcome and morbidity of ANS in combination with radiotherapy. MATERIALS AND METHODS: The treatment policy was to carry out four-node, Edinburgh-style ANS except in those cases with either palpably enlarged nodes or cytological confirmation of involvement or with clinically obvious node involvement at surgery when level 2 axillary node clearance (ANC) was carried out. Patients with involved nodes after ANS received postoperative axillary radiotherapy. RESULTS: In total, 381 patients were included, 331 received ANS and 50 received ANC. The median follow-up was 6.5 years and overall survival at 5 years was 84%. Pathologically involved nodes were found in 152/331 (50%) ANS patients and 43/50 (86%) ANC patients. The rate of local recurrence (breast or chest wall) at 5 years was 4% (95% confidence interval 1-17%) in the ANC group and 2% (95% confidence interval 1-4%) in the ANS group. The nodal recurrence rate of those undergoing ANS was 3% (11/331) compared with 6% (3/50) for those treated by ANC. The rate of clinically significant lymphoedema at 5 years was significantly higher (P=0.01) in the ANC arm: 18% (95% confidence interval 9-32%) compared with 5% (95% confidence interval 3- 8%) in those treated by ANS. Thirty-one cases received additional supraclavicular fossa irradiation because of the involvement of more than four nodes on ANS, which may not have been available with sentinel node biopsy and has implications for current practice. CONCLUSIONS: Selective ANS with the removal of a minimum of four nodes guides optimal locoregional treatment with good local control rates, low overall morbidity and may obviate the need for a second surgical procedure. PMID: 18722758 [PubMed - as supplied by publisher] __________________________________________________________________ J Invest Dermatol. 2008 Aug 21. [Epub ahead of print]Functional Analysis of FLT4 Mutations Associated with Nonne-Milroy Lymphedema.Verstraeten VL, Holnthoner W, van Steensel MA, Veraart JC, Bladergroen RS, Heckman CA, Keskitalo S, Frank J, Alitalo K, van Geel M, Steijlen PM. [1] 1Department of Dermatology, University Hospital Maastricht, Maastricht, The Netherlands [2] 2School for Oncology and Development (GROW), Maastricht University, Maastricht, The Netherlands. PMID: 18719607 [PubMed - as supplied by publisher] __________________________________________________________________ Trop Med Int Health. 2008 Aug 21. [Epub ahead of print]Tekola F, Ayele Z, Mariam DH, Fuller C, Davey G. Brighton and Sussex Medical School, Brighton, UK. Objective To develop and test a robust clinical staging system for podoconiosis, a geochemical disease in individuals exposed to red clay soil. Methods We adapted the Dreyer system for staging filarial lymphoedema and tested it in four re-iterative field tests conducted in an area of high-podoconiosis prevalence in Southern Ethiopia. The system has five stages according to proximal spread of disease and presence of dermal nodules, ridges and bands. We measured the 1-week repeatability and the inter- observer agreement of the final staging system. Results The five-stage system is readily understood by community workers with little health training. Kappa for 1-week repeatability was 0.88 (95% CI 0.80- 0.96), for agreement between health professionals was 0.71 (95% CI 0.60-0.82), while that between health professionals and community podoconiosis agents without formal health training averaged 0.64 (95% CI 0.52-0.78). Conclusions This simple staging system with good inter-observer agreement and repeatability can assist in the management and further study of podoconiosis. PMID: 18721188 [PubMed - as supplied by publisher] __________________________________________________________________ Ann Surg Oncol. 2008 Aug 15. [Epub ahead of print]Axillary Reverse Mapping in Breast Cancer: A New Microsurgical Lymphatic-Venous Procedure in the Prevention of Arm Lymphedema. Casabona F, Bogliolo S, Ferrero S, Boccardo F, Campisi C. Department of Obstetrics and Gynaecology, Breast Unit, San Martino Hospital, University of Genoa, Largo R. Benzi 1, 16132, Genoa, Italy. PMID: 18709416 [PubMed - as supplied by publisher] __________________________________________________________________ Cardiovasc Res. 2008 Sep 3. [Epub ahead of print]Adrenomedullin induces lymphangiogenesis and ameliorates secondary lymphoedema. Jin D, Harada K, Ohnishi S, Yamahara K, Kangawa K, Nagaya N. Department of Regenerative Medicine and Tissue Engineering, National Cardiovascular Center Research Institute, 5-7-1 Fujishirodai, Suita, Osaka 565-8565, Japan. Department of Regenerative Medicine and Tissue Engineering, National Cardiovascular Center Research Institute, 5-7-1 Fujishirodai, Suita, Osaka 565-8565, Japan. AIMS: Adrenomedullin (AM) is a multifunctional peptide hormone that plays a significant role in vasodilation and angiogenesis. Lymphoedema is a common but refractory disorder that is difficult to be treated with conventional therapy. We therefore investigated whether AM promotes lymphangiogenesis and improves lymphoedema. METHODS AND RESULTS: The effects of AM on lymphatic endothelial cells (LEC) were investigated. AM promoted proliferation, migration, and network formation of cultured human lymphatic microvascular endothelial cells (HLMVEC). AM increased intracellular cyclic adenosine monophosphate (cAMP) level in HLMVEC. The cell proliferation induced by AM was inhibited by a cAMP antagonist and mitogen-activated protein kinase kinase (MEK) inhibitors. Phosphorylated extracellular signal-regulated kinase (ERK) in HLMVEC was increased by AM. Continuous administration of AM (0.05 microg/kg/min) to BALB/c mice with tail lymphoedema resulted in a decrease in lymphoedema thickness. AM treatment increased the number of lymphatic vessels and blood vessels in the injury site. CONCLUSION: AM promoted LEC proliferation at least in part through the cAMP/MEK/ERK pathway, and infusion of AM induced lymphangiogenesis and improved lymphoedema in mice. PMID: 18708640 [PubMed - as supplied by publisher] ___________________________________________________________________ Ann Surg. 2008 Aug;248(2):286-93.Defining lower limb lymphedema after inguinal or ilio-inguinal dissection in patients with melanoma using classification and regression tree analysis. Spillane AJ, Saw RP, Tucker M, Byth K, Thompson JF. Sydney Melanoma Unit at the Sydney Cancer Centre, Royal Prince Alfred Hospital, Sydney, Australia. andrew.spillane@smu.org.au OBJECTIVE: This study aims to objectively define the criteria for assessing the presence of lymphedema and to report the prevalence of lymphedema after inguinal and ilio-inguinal (inguinal and pelvic) lymph node dissection for metastatic melanoma. SUMMARY BACKGROUND DATA: Lymphedema of the lower limb is a common problem after inguinal and ilio-inguinal dissection for melanoma. The problem is variably perceived by both patients and clinicians. Adding to the confusion is a lack of a clear definition or criteria that allow a diagnosis of lymphedema to be made using the various subjective and objective diagnostic techniques available. METHODS: Lymphedema was assessed in 66 patients who had undergone inguinal or ilio-inguinal dissection. Nine patients received postoperative radiotherapy. Assessment was performed by limb circumference measurements at standardized intervals, volume displacement measurements, and volumetric assessment calculated using an infrared optoelectronic perometer technique. Comparisons were made with the contralateral untreated limb. Patient assessment of the severity of lymphedema was compared with objective measures of volume discrepancy. Classification and regression tree analysis was used to determine a threshold fractional leg volume or circumference increase above which patients could self-detect volume changes that they reliably considered to indicate lymphedema. RESULTS: Based on classification and regression tree analysis, both the whole limb perometer volume percentage change > or = 15% and the sum of circumferences (of 6 defined sites along the limb) percentage change > or = 7% performed well overall in predicting moderate or severe perceived swelling (defined as "lymphedema"). Both definitions predicted lymphedema in approximately the same fraction of patients with misclassification rates of 16% and 15%, sensitivity 56% and 50%, specificity 95% and 100%, respectively. Using > or = 15% of whole perometer volume percentage change, 12% of patients with inguinal dissection had lymphedema compared with 23% of patients with ilio-inguinal dissection. Combining both groups, 18% of patients had lymphedema, positive and negative predictive values 82% and 84%. Using the definition > or = 7% of the sum of circumferences percent change, 7% of patients with inguinal dissection had lymphedema compared with 19% of patients with ilio-inguinal dissection (overall 14% had lymphedema, positive and negative predictive values 100% and 82%, respectively). Of the variables assessed, only radiotherapy was significantly associated with predicted lymphedema (OR 12.6; 95% CI 1.7 to > 100; P = 0.001 using whole perometer change > or = 15%; and OR 13.0; 95%CI 1.4 to > 100; P = 0.021 using sum circumference change > or = 7%). CONCLUSIONS: A whole limb perometer volume percentage change of > or = 15% and increase in the sum of circumferences of the defined points along the limb > or = 7% provide robust definitions of lower limb lymphedema. PMID: 18650640 [PubMed - indexed for MEDLINE] __________________________________________________________________ PLoS ONE. 2008 Aug 13;3(8):e2936.Global eradication of lymphatic filariasis: the value of chronic disease control in parasite elimination programmes. Michael E, Malecela MN, Zervos M, Kazura JW. Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom. The ultimate goal of the global programme against lymphatic filariasis is eradication through irrevocable cessation of transmission using 4 to 6 years of annual single dose mass drug administration. The costs of eradication, managerial impediments to executing national control programmes, and scientific uncertainty about transmission endpoints, are challenges to the success of this effort, especially in areas of high endemicity where financial resources are limited. We used a combined analysis of empirical community data describing the association between infection and chronic disease prevalence, mathematical modelling, and economic analyses to identify and evaluate the feasibility of setting an infection target level at which the chronic pathology attributable to lymphatic filariasis--lymphoedema of the extremities and hydroceles--becomes negligible in the face of continuing transmission as a first stage option in achieving the elimination of this parasitic disease. The results show that microfilaria prevalences below a threshold of 3.55% at a blood sampling volume of 1 ml could constitute readily achievable and sustainable targets to control lymphatic filarial disease. They also show that as a result of the high marginal cost of curing the last few individuals to achieve elimination, maximal benefits can occur at this threshold. Indeed, a key finding from our coupled economic and epidemiological analysis is that when initial uncertainty regarding eradication occurs and prospects for resolving this uncertainty over time exist, it is economically beneficial to adopt a flexible, sequential, eradication strategy based on controlling chronic disease initially. Publication Types: Research Support, N.I.H., ExtramuralPMID: 18698350 [PubMed - in process] PMCID: PMC2490717 __________________________________________________________________ Cancer Treat Rev. 2008 Aug 6. [Epub ahead of print]Breast cancer-related lymphoedema risk reduction advice: A challenge for health professionals. Nielsen I, Gordon S, Selby A. Discipline of Physiotherapy, James Cook University, Townsville, QLD 4811, Australia. Breast cancer-related lymphoedema (BCRL) is a debilitating, distressing condition affecting approximately one in five breast cancer survivors (Clark B, Sitzia J, Harlow W. Incidence and risk of arm oedema following treatment for breast cancer: a three-year follow-up study. QJM 2005;98:343-8). The evidence-base for breast cancer-related lymphoedema risk reduction advice is scant and contradictory, with most studies in the area limited by small numbers, retrospective design and other methodological inadequacies. Current advice has the capacity to profoundly alter quality of life following treatment for breast cancer. Health professionals should review the risk reduction advice they provide to reflect the current understanding of aetiology and risk factors. Further research is required to provide more evidence for the content, to identify optimal methods of precautionary education delivery and to determine the effect of the advice on the patient's quality of life and perception of recovery. PMID: 18691823 [PubMed - as supplied by publisher] __________________________________________________________________ Cancer J. 2008 Jul-Aug;14(4):216-22.Sentinel lymph node biopsy and axillary dissection: added morbidity of the arm, shoulder and chest wall after mastectomy and reconstruction. Sclafani LM, Baron RH. Department of Surgery, Breast Service, Memorial Sloan Kettering Cancer Center, Cornell University Medical College, New York 10065, USA. sclafanl@mskcc.org Axillary lymph node surgery is essential for the treatment of breast cancer but can produce both short- term and long-term morbidities, including lymphedema, shoulder restriction, numbness, weakness, and pain syndromes which impact on the quality of life of the estimated 2 million breast cancer survivors living in the United States today. They occur with both sentinel node biopsy and axillary dissection, though less frequently with the former. The incidence and etiology of these complications are investigated as are the risk factors, and methods of prevention and treatment. Recommendations for avoiding these morbidities for postoperative rehabilitation are discussed. PMID: 18677128 [PubMed - in process] __________________________________________________________________ Thorac Cardiovasc Surg. 2008 Aug;56(5):306-8.Primary chylopericardium with pulmonary lymphedema. Miyoshi K, Nakagawa T, Kokado Y, Matsuoka T, Kameyama K, Okumura N. Thoracic Surgery, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama, Japan. kmiyosh@almond.ocn.ne.jp PMID: 18615382 [PubMed - in process] ----------------------------------------------------------------------------- SEPTEMBER 2008 LYMPHEDEMA ABSTRASTS Arch Dermatol. 2008 Sep;144(9):1217-22.Related Articles, Links Cutaneous tumors, massive lymphadenopathy, and secondary lymphedema in a 16-year-old boy--quiz case. African/endemic Kaposi sarcoma (KS): lymphadenopathic form. Patel AR, Charles CA, Ricotti CA, Romanelli P, Connelly EA. University of Miami, Miami, Florida, USA. PMID: 18794470 [PubMed - in process]http://www.ncbi.nlm.nih.gov/pubmed/18794470? dopt=Abstract ------------------------------------------------------------------------ J Cancer Surviv. 2008 Sep 16. [Epub ahead of print]Related Articles, Links Arm/hand swelling and perceived functioning among breast cancer survivors 12 years post-diagnosis: CALGB 79804. Oliveri JM, Day JM, Alfano CM, Herndon JE 2nd, Katz ML, Bittoni MA, Donohue K, Paskett ED. Comprehensive Cancer Center, The Ohio State University, A356 Starling-Loving Hall, 320 W. 10th Avenue, Columbus, OH, USA. INTRODUCTION: Lymphedema is an under-reported and debilitating consequence of axillary node dissection among breast cancer survivors. This study describes the characteristics of arm and hand swelling in relation to perceived physical and mental health functioning among breast cancer survivors 9- 16 years post-diagnosis who previously participated in a clinical trial coordinated by the Cancer and Leukemia Group B (CALGB 8541). METHODS: Eligible survivors of CALGB 8541 completed questionnaires assessing demographics, arm/hand swelling, perceived physical functioning, and mental health. RESULTS: Two hundred forty-five women (94% white, mean age = 63, on average 12.4 years post-diagnosis) completed questionnaires (participation rate = 78%). Seventy-five women (31%) reported arm/hand swelling since their surgery. Of these women, 76% reported current swelling and half reported constant swelling, mainly in the upper arm. Swelling was reported as mild or moderate in 88% of the women. Women who reported severe swelling had significantly worse physical functioning and trended toward worse depressive symptoms and poorer mental health (lower mental SF-36 scores) as well. Activity-limiting swelling was also significantly associated with worse physical functioning. Although swelling interfered with wearing clothing (36%) and perceptions about general appearance (32%), only 37% of women sought treatment for swelling. CONCLUSIONS: Arm/hand swelling is a chronic problem for a subgroup of long-term survivors of breast cancer, negatively affecting physical functioning. IMPLICATIONS FOR CANCER SURVIVORS: Educational efforts are needed as part of a comprehensive survivorship care plan to raise awareness about lymphedema so that survivors may identify this complication, seek treatment early, and potentially improve their physical functioning. PMID: 18792786 [PubMed - as supplied by publisher] http://www.ncbi.nlm.nih.gov/pubmed/18792786?dopt=Abstract ------------------------------------------------------------------------- Eur J Cancer Care (Engl). 2008 Sep 3. [Epub ahead of print]Related Articles, Links Treatment for upper-limb and lower-limb lymphedema by professionals specializing in lymphedema care. Langbecker D, Hayes SC, Newman B, Janda M. School of Public Health and Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Queensland, Australia. Up to 60% of patients with cancer of the vulva, and between 20 and 30% of patients with breast or abdominal cancers may develop lymphedema following treatment. The aims of this study were to assess health professionals' knowledge about treatment, diagnostic procedures, advice and confidence in treatment of patients with either upper-limb (ULL) or lower-limb lymphoedema (LLL), and whether these differed by health professionals' background or for patients with ULL compared with LLL. A cross-sectional telephone interview was undertaken in 2006, of 63 health professionals (response rate 92.6%) known to treat lymphedema. Sixty-three per cent of the health professionals were physiotherapists; the majority were university-trained, with 20 years' experience or more. Ninety-five per cent of health professionals used circumferential measurements to establish lymphedema status, and most health professionals advised avoiding scratches and cuts (100%), insect bites (98.4%), sunburn (98.4%) and excessive exercise (65.1%) on the affected limb. Health professionals reported that compared with patients with LLL, patients with ULL were more likely to present within the first 3 months of being symptomatic (P < 0.01). Patients with LLL were more likely to present with swelling (P = 0.001), heaviness (P = 0.003), tightness (P = 0.007) and skin problems (P < 0.001) compared with patients with ULL. Treatment and advice differed according to health professionals' background, but not location of lymphedema (ULL vs. LLL). Assessment, treatment and advice for lymphedema vary across professional groups. Our results suggest that improvements should be attempted in the early detection of lymphedema, in particular of LLL among cancer patients. PMID: 18771539 [PubMed - as supplied by publisher] http://www.ncbi.nlm.nih.gov/pubmed/18771539?dopt=Abstract --------------------------------------------------------------------------- Ann Trop Med Parasitol. 2008 Sep;102(6):529-40.Related Articles, Links Elephantiasis of non-filarial origin (podoconiosis) in the highlands of north-western Cameroon. Wanji S, Tendongfor N, Esum M, Che JN, Mand S, Tanga Mbi C, Enyong P, Hoerauf A. Research Foundation for Tropical Diseases and Environment, P.O. Box 474, Buea, Cameroon; Department of Biochemistry and Microbiology, University of Buea, P.O. Box 63, Buea, Cameroon. swanji@yahoo.fr Lymphoedema, a condition of localized fluid retention, results from a compromised lymphatic system. Although one common cause in the tropics is infection with filarial worms, non-filarial lymphoedema, also known as podoconiosis, has been reported among barefoot farmers in volcanic highland zones of Africa, Central and South America and north-western India. There are conflicting reports on the causes of lymphoedema in the highland regions of Cameroon, where the condition is of great public-health importance. To characterise the focus of lymphoedema in the highlands of the North West province of Cameroon and investigate its real causes, a cross-sectional study was carried out on the adults (aged > or =15 years) living in the communities that fall within the Ndop and Tubah health districts. The subjects, who had to have lived in the study area for at least 10 years, were interviewed, examined clinically, and, when possible, checked for microfilaraemia. The cases of lymphoedema confirmed by ultrasonography and a random sample of the other subjects were also tested for filarial antigenaemia. The interviews, which explored knowledge, attitudes and perceptions (KAP) relating to lymphoedema, revealed that the condition was well known, with each study community having a local name for it. Of the 834 individuals examined clinically, 66 (8.1%) had lymphoedema of the lower limb, with all the clinical stages of this condition represented. None of the 792 individuals examined parasitologically, however, had microfilariae of W. bancrofti (or any other filarial parasite) in their peripheral blood, and only one (0.25%) of the 399 individuals tested for the circulating antigens of W. bancrofti gave a positive result. In addition, none of the 504 mosquitoes caught landing on human bait in the study area and dissected was found to harbour any stage of W. bancrofti. These findings indicate that the elephantiasis seen in the North West province of Cameroon is of non-filarial origin. Publication Types: Research Support, Non-U.S. Gov't PMID: 18782492 [PubMed - in process] http://www.ncbi.nlm.nih.gov/pubmed/18782492?dopt=Abstract ----------------------------------------------------------------------------- Gynecol Oncol. 2008 Sep 3. [Epub ahead of print]Related Articles, Links Primary pelvic exenteration in cervical cancer patients. Ungar L, Palfalvi L, Novak Z. Gynecologic Oncology Department, Hungarian National Cancer Institute, Hungary. OBJECTIVE: Despite the reports of a number of leading institutions concerning the use of primary exenteration, there are differences in regard to definition, indications, and interpretation of results of this treatment approach to cervical cancer. In this paper we present our own experience with 41 cervical cancer patients treated with primary exenteration at St. Stephen Hospital Budapest. We explore some important unsettled aspects (definition, indications, and quality of life consequences) of this treatment modality in view of our own experience and the literature. METHODS: Between January 1993 and June 2006, 2540 invasive cervical cancer patients were seen at the gynecologic oncology service of the St. Stephens Hospital Budapest. Two hundred twelve (8%) of these patients were surgically explored with the plan of an exenterative surgery. Exenteration was the primary treatment in 41 (25%) of 166 completed exenterations; these 41 cases included 2 cases of supralevator total exenteration, 9 cases of supralevator anterior exenteration, and 30 cases of partial supralevator anterior exenteration. In the 2 total exenteration patients, anal function was restored with a low rectal anastomosis, with a temporary defunctioning colostomy in 1 patient. Urethral function was restored in 9 out of 11 supralevator exenteration cases with the Budapest pouch bladder replacement technique. In the remaining 2 cases, a Bricker conduit was used for urinary diversion. RESULTS: There was no operation-related mortality in this cohort of patients. An external fecal or urinary stoma was avoided in 38 (93%) out of the 41 primary exenteration patients; in 1 patient a temporary defunctioning colostomy was used; and in 2 patients a permanent ileal conduit was created. In 9 patients (22%), complications (ileus and peritonitis, occlusion of the femoral artery, stricture of the implanted ureter, and postoperative ureterovaginal fistula) necessitated surgical intervention. A quality of life study revealed the need for prolonged self- catheterization, partial (mainly night time) incontinence, and lymphedema in 7 patients. CONCLUSION: We consider and suggest that an en bloc resection of part(s) of the urinary bladder and/or the rectum with the uterine cervix should be considered an exenteration (partial exenteration). A 50% survival rate of a select group of stage IVA cervical cancer patients treated with primary exenteration can be considered significant, but cannot be considered superior to that of chemoradiation therapy. The same applies when considering treatment-related mortality and complications that require operative interventions. Low rectal anastomosis and orthotopic bladder replacement with a relative low risk of fistula formation in non-irradiated patients constitute a strong quality of life argument in favor of primary exenteration in a select group of stage IVA cervical cancer patients. PMID: 18775558 [PubMed - as supplied by publisher] http://www.ncbi.nlm.nih.gov/pubmed/18775558?dopt=Abstract -------------------------------------------------------------------------- Jpn J Clin Oncol. 2008 Sep 5. [Epub ahead of print]Related Articles, Links Autologous Bone Marrow Stromal Cells Transplantation for the Treatment of Secondary Arm Lymphedema: A Prospective Controlled Study in Patients with Breast Cancer Related Lymphedema. Hou C, Wu X, Jin X. Department of Vascular Surgery, Shandong Provincial Hospital, Shandong University, Shandong, China. OBJECTIVE: To determine the short- and long-term effect of bone marrow stromal cells (BMSCs) transplantation as a treatment for breast cancer-related lymphedema. To contrast it with complex decongestive physiotherapy (CDT). METHODS: Fifteen women with lymphedema, who had undergone breast cancer surgery and/no radiotherapy 5 years before, served as the experimental group and received BMSC transplantation; 35 patients were measured as the control group treated with CDT. They were kept on follow-up for 1 year. RESULTS: Two patients in the CDT Group failed to keep follow-up. Before treatment, patients had average volume of edema in the affected arm of 1166.2 ml in BMSC Group and 1091.0 ml in the CDT Group. With therapy, there was an average decrease in lymphedema volume of 730.7, 887.9 and 958.6 ml in the BMSC Group and 714.8, 657.9 and 571.3 ml in the CDT Group after 1, 3 and 12 months, respectively. Before treatment, the percentage of lymphedema was 28.6% in the BMSC Group and 26.8% in the CDT Group. After treatment, there was a decrease of 64.6, 78.5 and 81.0% in the BMSC Group and 67.2, 60.4 and 54.5% in the CDT Group after 1, 3 and 12 months, respectively. When asked to quantify subjectively their pain on a numeric scale from 0 to 5, the average score of these patients was 3.4 in the BMSC group and 4.0 in the CDT Group. The average score was reduced to 1.6, 0.8 and 0.6 in the BMSC Group and to 1.2, 1.7 and 1.6 in CDT Group after 1, 3 and 12 months, respectively. CONCLUSIONS: Autologous BMSCs transplantation for the treatment of breast cancer related lymphedema is effective and feasible. PMID: 18776199 [PubMed - as supplied by publisher] http://www.ncbi.nlm.nih.gov/pubmed/18776199?dopt=Abstract -------------------------------------------------------------------------- : Comput Biol Med. 2008 Nov 28. [Epub ahead of print]Related Articles, Links Staging of upper limb lymphedema from routine lymphoscintigraphic examinations. Gebouský P, Kárný M, Krížová H, Wald M. Department of Adaptive Systems, Institute of Information Theory and Automation, Academy of Sciences of the Czech Republic, P.O. Box 18, 182 08 Prague 8, Czech Republic. Secondary lymphedema of upper limbs, a frequent complication after a breast cancer therapy, can be successfully treated only when diagnosed at an early, ideally latent, stage. Lymphoscintigraphy is a promising candidate to this purpose. A slow lymphatic dynamics of upper limbs allows, however, a routine collection at most three images reflecting it. This makes an exploitation of lymphoscintigraphy to early-stage diagnosis a complex task. Recently, a Bayesian methodology extracting diagnostic information from the available sparse data has been developed. It properly detects lymphedema occurrence but not a desirable disease staging. The present paper proposes Bayesian diagnostic processing of lymphoscintigraphic and routine clinical data. Its staging ability was tested on diagnostic data of 88 women at the age of 39-84 years (60.2+/-10.4) with a suspicion of unilateral secondary lymphedema of upper limbs caused by a breast cancer treatment. Less than 20 of them had simply detectable disease stages. Information about accumulation dynamics of the lymphatic system contained in lymphoscintigraphic images was quantified via estimation of a simplified accumulation model [P. Gebouský, M. Kárný, A. Quinn, Lymphoscintigraphy of upper limbs: a Bayesian framework, in: J.M. Bernardo, M.J. Bayarri, J.O. Berger (Eds.), Bayesian Statistics, vol. 7, University Press, Oxford, 2003, pp. 543-552]. The sole use of this approach, referred as "Bayesian quantitative lymphoscintigraphy", was found insufficient for a finer staging of the disease to typical categories (healthy, latent, reversible, spontaneously irreversible, elephantiasis). For this reason, the results of Bayesian quantitative lymphoscintigraphy were attached to routinely available qualitative lymphoscintigraphic inspection and clinical data. These combined data were modelled by normal probabilistic mixtures. Their Bayesian estimates were used for a computerized disease staging. The resulting model predicts expert's conclusions on the presence of a lymphedema in 95% cases. A finer staging is successful in 85% cases of suspicious limbs. Model cross-validation and a closer look on patients' data indicate that the combined data are still insufficiently informative. It calls for the further improvements of the inspection methods. Even under the current inspection conditions, the proposed processing provides clinicians a reliable quantitative "second" opinion on the disease staging. PMID: 19041964 [PubMed - as supplied by publisher] http://www.ncbi.nlm.nih.gov/pubmed/19041964?dopt=Abstract ------------------------------------------------------------- Comput Biol Med. 2008 Nov 28. [Epub ahead of print]Related Articles, Links Staging of upper limb lymphedema from routine lymphoscintigraphic examinations. Gebouský P, Kárný M, Krížová H, Wald M. Department of Adaptive Systems, Institute of Information Theory and Automation, Academy of Sciences of the Czech Republic, P.O. Box 18, 182 08 Prague 8, Czech Republic. Secondary lymphedema of upper limbs, a frequent complication after a breast cancer therapy, can be successfully treated only when diagnosed at an early, ideally latent, stage. Lymphoscintigraphy is a promising candidate to this purpose. A slow lymphatic dynamics of upper limbs allows, however, a routine collection at most three images reflecting it. This makes an exploitation of lymphoscintigraphy to early-stage diagnosis a complex task. Recently, a Bayesian methodology extracting diagnostic information from the available sparse data has been developed. It properly detects lymphedema occurrence but not a desirable disease staging. The present paper proposes Bayesian diagnostic processing of lymphoscintigraphic and routine clinical data. Its staging ability was tested on diagnostic data of 88 women at the age of 39-84 years (60.2+/-10.4) with a suspicion of unilateral secondary lymphedema of upper limbs caused by a breast cancer treatment. Less than 20 of them had simply detectable disease stages. Information about accumulation dynamics of the lymphatic system contained in lymphoscintigraphic images was quantified via estimation of a simplified accumulation model [P. Gebouský, M. Kárný, A. Quinn, Lymphoscintigraphy of upper limbs: a Bayesian framework, in: J.M. Bernardo, M.J. Bayarri, J.O. Berger (Eds.), Bayesian Statistics, vol. 7, University Press, Oxford, 2003, pp. 543-552]. The sole use of this approach, referred as "Bayesian quantitative lymphoscintigraphy", was found insufficient for a finer staging of the disease to typical categories (healthy, latent, reversible, spontaneously irreversible, elephantiasis). For this reason, the results of Bayesian quantitative lymphoscintigraphy were attached to routinely available qualitative lymphoscintigraphic inspection and clinical data. These combined data were modelled by normal probabilistic mixtures. Their Bayesian estimates were used for a computerized disease staging. The resulting model predicts expert's conclusions on the presence of a lymphedema in 95% cases. A finer staging is successful in 85% cases of suspicious limbs. Model cross-validation and a closer look on patients' data indicate that the combined data are still insufficiently informative. It calls for the further improvements of the inspection methods. Even under the current inspection conditions, the proposed processing provides clinicians a reliable quantitative "second" opinion on the disease staging. PMID: 19041964 [PubMed - as supplied by publisher] http://www.ncbi.nlm.nih.gov/pubmed/19041964?dopt=Abstract -------------------------------------------------------- Breast Cancer Res Treat. 2008 Dec 4. [Epub ahead of print]Related Articles, Links Lymphatic drainage in the muscle and subcutis of the arm after breast cancer treatment. Stanton AW, Modi S, Bennett Britton TM, Purushotham AD, Peters AM, Levick JR, Mortimer PS. Cardiac & Vascular Sciences (Dermatology), St George's Hospital Medical School, University of London, Cranmer Terrace, London, SW17 0RE, UK. Breast cancer-related lymphoedema of the arm (BCRL) results from impaired lymph drainage after axillary surgery. Little is known about lymphatic changes in the arm between surgery and oedema onset. We measured forearm muscle and subcutis lymph drainage in 36 women at 7 and 30 months after surgery by quantitative lymphoscintigraphy. None had BCRL initially but 19% had BCRL by 30 months. At 7 months muscle and subcutis drainage in both arms of BCRL-destined women exceeded that of non- BCRL women (P < 0.01). Muscle lymph drainage always exceeded subcutis drainage (P < 0.0001). Muscle lymph drainage in the ipsilateral arm was unimpaired relative to the contralateral arm. BCRL therefore developed in women with higher peripheral lymph flows. The major lymphatic load was generated by muscle; there was no pre-BCRL lymphatic impairment in the muscle of the ipsilateral arm. We propose that some women have a defined, constitutive predisposition to secondary lymphoedema. Specifically, women with higher filtration rates, and therefore higher lymph flows through the axilla that are closer to the maximum sustainable, are at greater risk of BCRL following axillary trauma, even following removal of 1-2 nodes. PMID: 19052859 [PubMed - as supplied by publisher] http://www.ncbi.nlm.nih.gov/pubmed/19052859?dopt=Abstract ------------------------------------------------------------------- November 10, 2008 Oneindia, India Guidelines To Improve Quality Of Life After Breast Cancer Treatment Even after you are treated from the deadly breast cancer , it becomes a prime responsibility of the patient to be able to handle the side affects of the treatments. Staying active, acting early and learning the warning signs of lymphedema – an adverse effect of breast cancer treatment caused by damage to the lymph system – can help women fighting the deadly disease avoid developing chronic lymphedema. That's what the German Institute for Quality and Efficiency in Health Care (IQWiG) has suggested that women can learn more about how to protect themselves from this common and distressing adverse effect of treatment. Lymphedema is an adverse effect of breast cancer treatment caused by damage to the lymph system. When the lymph system cannot properly remove fluids from around the breast and arm, the fluid gathers and the arm swells. This causes pain and restricts movement. It could become a chronic problem that is hard to treat. Breast cancer patients can also handle the condition at the Institute's website, www.informedhealthonline. org. With increasing survival rate, breast cancer treatment is becoming more effective. This, according to the German Institute ups the importance of the quality of life for survivors. "Even with many women having less aggressive breast cancer treatments, around 10 to 20percent will develop lymphedema. We doctors still underestimate the impact on patients' quality of life of treatment adverse effects like lymphedema. The first step to prevention is using therapies that limit the damage to the woman's lymph system," said Professor Peter Sawicki, the Institute's Director. The next step to better quality of life is to stay active. For a long time, doctors have warned women to limit the use of the arm and be careful about being too active after breast cancer treatment. The treatment shown to be effective in trials is compression therapy with bandages or compression sleeves. A special massage technique called lymphatic drainage as well as physiotherapy might be able to help, but this has not been so well-studied. But Sawicki said, "While women who are developing lymphedema have to protect their arms more, the blanket warnings from the past to all women with breast cancer were never based on strong scientific evidence. In fact, trials of exercise in women with breast cancer have shown that it can improve quality of life without increasing the risk of lymphedema." However women need to learn about the warning signs of lymphedema and act early. "A feeling of heaviness, heat and swelling in the arm - women need to take action early when this happens in the years after breast cancer treatment. Lymphedema is easier to treat effectively in the early stages," said Sawicki. __________________________________________________________________ November 10, 2008 Delmarva Now MEETINGS ON DELMARVA LYMPHEDEMA SUPPORT GROUP. Tuesday, 11 a.m.-noon. Avery W. Hall Education Building, Salisbury. 410-548-7880. __________________________________________________________________ Nov 10, 2008 Naples Daily News Health Briefs: Nov. 11, 2008 Exercise Movin’ On, an exercise and movement program for breast cancer survivors, will be held for one hour for six weeks beginning Tuesday and continuing through Dec. 16 in Naples. This free event is presented by Lymphedema Resources and funded by a grant from the Community Trust Fund of the League Club. Information: 992-4965 __________________________________________________________________ November 10, 2008 North Bay Nugget NORTH BAY AND AREA SUPPORT GROUPS Lymphedema education and support group meets at 7 p. m. the third Thursday of each month at Emmanuel United Church, 395 Lakeshore Dr. For information, call Susan at 497-0683. __________________________________________________________________ November 11, 2008 ABC News 4, WCIV New Lymph Node Surgery Reduces Swelling Charleston - It is a surgical procedure uncommon in the United States performed today at Roper hospital on a breast cancer patient. The novel treatment helps reduce painful swelling. The patient had cancerous lymph nodes removed from under her arm so lymph nodes were taken from her stomach then transplanted under her arm. Jane Dinnan, 51, beat cancer by undergoing chemotherapy and radiation. Just when she thought her ordeal was over she developed lymphedema in her right arm, which is a build up of fluid. "That gets stuck in your arm and it causes your arm to swell, your hand to swell. In my case my breast is also swollen," Dinnan explained. She says she's in constant pain and her arm feels like lead. Dinnan wears a compression sleeve to help with the swelling. But help is on the way. Reconstructive plastic surgeon, Dr. Marga Massey, will perform Jane's vascularized lymph node transfer. The procedure begins by harvesting lymph nodes from Jane’s groin. A flap of skin is removed, giving Jane an instant tummy tuck. "So you take a little community of lymph nodes still attached to one another. The soft tissue surrounding those lymph nodes have cells that have growth factors. With time over 12 to 24 months after recovery with adequate massage and maintenance of your arm, new lymph channels will grow down into the hand," Dr. Massey said. Vascularized lymph node transfer is more popular in France . Dr. Corrine Becker, from Paris , is a specialist and is a consultant on the case. Dr. Massey has worked with Dr. Becker many times. Jane's right breast was also removed. The skin and fat flap will also be used to construct a new breast. This procedure is not a cure for lymphedema, but the doctors are hopeful. "Our anticipated outcome for Jane would be that she won't have a breast that swells and becomes heavy and that her arm won't be as swollen or feel as heavy," Dr. Massey said. Jane came through the surgery well and will spend about four days in the hospital. _____________________________________________________________________________ November 11, 2008 Live 5 News Marika Kelderman New surgery offers hope for those recovering from breast cancer CHARLESTON, SC (WCSC) - Many women fighting breast cancer have to have their lymph nodes removed as part of the treatment. It increases their chance of survival, but can also cause a painful and incurable side effect -- Lymphoedema, or the swelling of parts of the body. But a new surgery at Roper Hospital is helping women fight the bad effects of lymph node removal, and keep the benefits. Jane Dinnan was diagnosed with breast cancer in October of last year. She underwent a lumpectomy, chemotherapy, radiation and had 17 lymphnodes removed. It left her cancer free but suffering from sever lymphoedema in her left arm and breast. "Your arm gets very heavy and swollen and your hand and your arm and in my case also my breast is very heavy and swollen with lymphoedema." For Jane, the condition has been debilitating and common treatments like compression and massage have not helped. "When you are laying there and your aching and your arm is lead and your thinking there is nothing they can do its depressing," she sad. But she found hope at Roper Hospital and underwent a mastectomy and reconstruction of her breast affected by lymphoedema as well a lymph node transplant, a procedure relatively new in the United States. Dr. Marga Massey, the surgeon in Jane's surgery, said they moved tissue from other places in her body to reconstruct Jane's breast. "She's going to have tissues from her stomach, her abdomen, the skin and extra fat and some associated lymph nodes from her groin transferred to her chest wall make a brand new breast and for surgical treatment of lymphoedemaThe surgery is lengthy and well take about six hours but the recovery time is relatively short. Jane should be walking and back at home in four days." While Lymphoedema is not curable, doctors believe the lymph node transplant will greatly reduce Jane's symptoms and she could see relief within two to 3 weeks. For Jane the surgery gives her one more way to fight breast cancer and all that comes with it." "This is hope. This is a lot of hope. I'm excited and I know a lot of women that are out there suffering is excited to hear about it," said Jane. Roper Hospital says the transplant can also be used to help those suffering from congenital lymphodemia. A male patient with the condition is schedule to have lymph nodes transplanted from his groin to his lower leg later this week. __________________________________________________________________ November 11, 2008 San Marcos Daily Record CTMC chamber Business of Year Central Texas Medical Center was named the San Marcos Chamber of Commerce Business of the Year at the Chamber’s Annual Meeting and Gala held recently at the new Embassy Suites in San Marcos. A crowd of more than 500 local business, community and political leaders gathered to celebrate the past year’s accomplishments of the chamber. Guests heard a presentation by nationally-recognized motivational speaker and author Randy Snow, followed by a program honoring the contribution of volunteers and organizations in the community. CTMC was one of three semi-finalists for the honor announced at the beginning of the evening’s program. The program concluded when Gloria Merrell, the Chamber’s Small Business Council’s chair, announced CTMC as the winner of the Chamber’s Business of the Year award. Merrell said, “This year’s Business of the Year has been a fixture in our community for 25 years. Employing 610 employees, working with 177 physicians, nearly 100 volunteers and a number of other companies and partners in our community, they provide millions of dollars each year in community benefit and involvement that improves and enhances the overall health and well-being of our community in many ways. “They care for the underprivileged that often cannot pay for their care. They care for the elderly by subsidizing their unreimbursed Medicare costs. They provide faith-based and spiritual support for families and the community,” she said. Merrell also spoke of the hospital’s economic impact on the region through good paying jobs and the additional jobs and city revenue to be created by the hospital’s $35 million expansion project currently underway on its Wonder World Drive campus. “This award is a testament to the work that everyone on our staff, our physicians and our volunteers do each day to make a difference in the lives of those we serve,” Gary Jepson, president and CEO, said. “While we don’t do what we do for the accolades per se, I have to admit that receiving such recognition helps to validate our mission to extend the healing ministry of Christ and certainly provides an emotional charge to each of us to continue working even harder to do more.” This latest acknowledgement and appreciation for the role CTMC plays in our community and region follows the Kyle Chamber’s Business of the Year bestowed on CTMC in 2007 and the San Marcos Hispanic Chamber’s naming of CTMC Hospice as Organization of the Year in 2007. CTMC is marking its 25th anniversary at its Wonder World Drive location this year and kicked off the year with the announcement of its expansion and renovation project and has continued growth and progress throughout the year with the creation of new services including a new Sleep Study Center a Lymphedema Therapy program and the addition of several new physicians including primary care specialists in San Marcos and Kyle. For more information about CTMC services, the expansion project, or to find a physician, call 353- 8979. __________________________________________________________________ November 11, 2008 International Business Times NYC Chiropractor Dr. Steven Shoshany Now Certified in Kinesio Taping. Dr. Steven Shoshany, a Chiropractor at Living Well Medical in Manhattan, is now a Certified Kinesio Practitioner. This technique was made public during the Summer 08 Olympics on the shoulder of Kerri Walsh. What is this tape? Can this tape help you with your bad knee ot painful shoulder? Find out why elite athletes use this tape to help speed recovery of their injuries. New York, NY (PRWEB) November 11, 2008 -- Dr. Steven Shoshany, a chiropractor at Manhattan's Living Well Medical, PC, is now a certified Kinesio Taping® practitioner. Dr. Shoshany's certification is a unique addition to the physical therapy and rehabilitation services offered at Living Well Medical. Dr. Shoshany will offer the method alongside other cutting-edge technologies and protocols, including spinal decompression and cold laser therapy, at his practice, Living Well Medical in Manhattan NYC. Developed by Japanese chiropractor Dr. Kenzo Kase more than 25 years ago, the Kinesio Taping Method has quickly become the standard for therapeutic rehabilitative taping. Though Dr. Shoshany has used the Kinesio Taping Method for more than five years, the method has just recently taken the rehabilitation and sports medicine world by storm. The Kinesio® method gained worldwide recognition during the 2008 Summer Olympics when it was worn by many athletes, most noticeably by U.S. Women's Volleyball player Kerri Walsh. "The Kinesio Taping Method enhances healing time and reduces swelling, and is fantastic in getting athletes and weekend warriors back to the activity they love without pain and restrictive braces and supports," says Dr. Shoshany. Kinesio Taping is a technique based on the body's own natural healing process. The method uses a uniquely designed and patented tape, Kinesio Tex Tape, for treatment of muscular disorders and lymphedema reduction. The method is applied over and around muscles to reduce pain and inflammation, to relax overused, tired muscles and to support muscles in movement on a 24-hour-per- day basis. It is non-restrictive type of taping that gives support and stability to joints and muscles without affecting circulation and range of motion. In contrast, traditional sports taping is wrapped around a joint strictly for stabilization and support during a sporting event, obstructing the flow of bodily fluids -- an undesirable side-effect. Kinesio Taping is also used for preventive maintenance, edema and pain management. It helps the body heal naturally, can be used preventatively, as treatment, in rehab, during competition or as a take-home treatment applied by a chiropractor. The tape can be used for anything from headaches to foot problems, including: muscular facilitation or inhibition in pediatric patients, carpal tunnel syndrome, lower back strain/pain (subluxations, herniated disc), knee conditions, shoulder conditions, hamstring, groin injury, rotator cuff injury, whiplash, tennis elbow, plantar fasciitis, patella tracking, ankle sprains and more. Kinesio Taping involves two techniques. The first technique gives the practitioner the opportunity to give support while maintaining a full range of motion. This enables the individual to participate in normal physical activity with functional assistance. The second technique, most commonly used in the acute stage of rehabilitation, helps prevent overuse or over-contraction and helps provide facilitation of lymph flow for a complete 24-hour period. Correctional techniques include mechanical, lymphatic, ligament/tendon, fascia, space and functional. Kinesio Tex Tape can be used in conjunction with other therapies, including cryotherapy, graston technique, massage therapy and electrical stimulation. Kinesio Taping exhibits its efficacy through the activation of neurological and circulatory systems. This method basically stems from the science of Kinesiology, hence the name "Kinesio". Muscles are not only attributed to the movements of the body, but also control the circulation of venous and lymph flows, body temperature, etc. Therefore, the failure of the muscles to function properly induces various kinds of symptoms. Consequently, so much attention was given to the importance of muscle function that the idea of treating the muscles in order to activate the body's own healing process came about. Using an elastic tape, it was discovered that muscles and other tissues could be helped by outside assistance. Employment of Kinesio Taping creates a totally new approach to treating nerves and muscles. For the first 10 years, chiropractors, acupuncturists and other medical practitioners were the main users of Kinesio Taping. Soon thereafter, the method was used by the Japanese Olympic volleyball players and word quickly spread to other athletes. Today, Kinesio Taping is accepted by medical practitioners and athletes in Japan, the United States, Europe, South America and other Asian countries. About Living Well Medical PC. in Manhattan NYC Living Well Medical is headed by Dr. Arnold Blank, a medical doctor who specializes in pain management. The facility is a hybrid between the medical and physical therapy industry, providing sports medicine, acupuncture, massage therapy, chiropractic care and herniated disc treatments utulizing non surgical spinal decompression. At Living Well Medical, each patient has an opportunity to meet with the doctor for a full evaluation, fitness test and to identify chronic pain issues. A personalized care plan is established and patients will meet weekly with their doctor, physical therapist and certified trainer to improve their quality of life through a combination of treatment, therapy and exercise. Utulizing state of the art equipment like the DRX 9000 spinal decompression unit, Digital radiographic imaging,SpineForce,Erchonia Cold laser equipment,Poweplate and the Kinesis by technogym Living Well Medical provides the most advanced rehabilitation available in NYC. __________________________________________________________________ November 11, 2008 Enterprise-Record Daily Planner: November 12 THERAPEUTIC MOVEMENT: 9-10 a.m. Healing class for women can be done sitting or standing. Helps regain range of motion, increase flexibility, reduce swelling from Lymphedema, promote positive self-image. Any age, fitness level. $10 fee first class. Enloe Cancer Center Conference Room, 251 Cohasset Road. Register, 332-3855. _________________________________________________________________ November 11, 2008 Baxterbulletin.com Lymphedema Support Group,noon, Peitz Cancer Support House, 315 Powers St. Facilitator: Renee Barnes, physical therapist, MS. 508-2273. _________________________________________________________________ November 13, 2008 The Gazette (Montreal), By BILL YOUNG, The Gazette Sharing the great dragon ladies' spirit Today's musings are about dragon ladies, not the shallow sirens of pulp fiction and B-movies, but the real thing, the West Island Dragon ladies. You might have heard of them. They race dragon boats in their spare time. And they are all breast cancer survivors. "Everyone's in the same boat," said a chuckling team manager June Pedersen of Hudson, herself cancer- free for 30 years. "We all share the same realities and dreams." The West Island Dragons (WID) are one of only three dragon boat racing crews in Quebec composed entirely of breast cancer survivors. They were established in June 2003, by former members of the Montreal club, Two Abreast, who started up with a 22-person team. Current numbers range between 20 and 30 paddlers of all ages. The WID mission is to "paddle together in celebration of life to demonstrate that there can be healthy, active living after breast cancer." Success is measured as much through adversity overcome and courage as victories - although winning is always nice. But make no mistake - they take their sport very seriously. Dragon boat racing is a newly popular recreational team sport. Crews of up to 20 paddlers sitting side- by-side in tapered boats, along with a steer-person and a bow-mounted drummer who sets the pace, regularly participate in competitions, called festivals. Races are seeded events, covering distances up to 500 metres, and take an exhausting two to four minutes to complete. Each summer, WID prepares to enter at least three festivals. The group trains together twice a week, with paddlers urged to do more on their own. Dragon boats were introduced to breast cancer rehabilitation in the mid-1990s by Vancouver sports medicine physician Don McKenzie. He believed that its straight-armed stroke, powered mainly by back muscles would strengthen the upper body and help combat the lymphedema that often leads to swelling in the arm following treatment. Within 10 years, his modest proposal had become a world-wide phenomenon. And it is easy to see why. For beyond the benefits that fitness brings, breast cancer survivors have discovered that the experience helps them face that other reality: members get sick, and some will die. "It can be tough," said June Pedersen, recalling fellow WID member, Gail Hand, who not long ago basked in the joy of life. "I remember her in 2005 at the post-festival party in Vancouver, dancing up a storm in a sea of fuchsia. In December 2005, her cancer returned. She fought like a dragon, but died in March 2007. In July 2008, our team placed a bench in her memory at our home base, the Pointe Claire Canoe Club, overlooking Valois Bay." It is not coincidental that survivors tend to display a delicious, frequently bawdy, sense of fun, often revealed in team names. Examples abound, from appellations like Abreast in a Boat or Canadians Abreast, to the naughtier Missabitatitty, from Australia." At dragon boat festivals, teams compete against all comers, according to their seeded positions. Factors like gender are not considered. Except for one event - the richly textured breast cancer survivor's challenge race and flower ceremony. Limited to breast cancer survivors, this race begins like any other. However, after all boats have crossed the finish line they are rafted together, and with soft music, perhaps Sarah McLaughlin's haunting I Will Remember You, carrying across the stillness, and each competitor is handed a flower. When they are ready, the paddlers toss the flowers overboard, watching intently as the brightly coloured posies bob and slip, and then drop out of sight. Other than the muffled strains of the melody and the sometimes sounds of sobbing stifled, there is only silence. After a time, the competitors come ashore and raise their paddles in an extended arch of honour. And the racing begins anew. You can learn more about the West Island Dragons by visiting www.westislanddragons.com/ Hudson resident Bill Young is co-author of the book, Remembering the Montreal Expos, with Danny Gallagher. _________________________________________________________________ November 13, 2008 Kingston Reporter By Paula Barrette Guest columnist: Remember quality of life During October – Breast Cancer Awareness Month – we invited folks who wanted to talk about their experiences with breast cancer to do just that, whether by interview or by writing their thoughts. Here is the second of three guest pieces, personal stories about dealing with breast cancer. I could write 100 pages on the subject of breast cancer. But the message I really want to convey is for women and their doctors to not settle simply for survival. I was diagnosed in June after a routine mammogram. A diagnosis of breast cancer was scary, but when I started researching treatments, I really became frightened. Quality of life was my primary concern, and all of the treatments included major problems. My options were surgery, chemotherapy, radiation and hormone therapy. One complication from surgery is lymphedema, a debilitating swelling of the arm on the affected side. Although I was told the incidence of lymphedema is 10 percent, my research indicates up to a 40 percent occurrence over the life of a breast cancer survivor. It doesn’t always happen after surgery, it can be one, two or five years later. A cut, a bug bite or sting, or an infection can trigger it. I heard some very sad stories. One woman said it affects every aspect of her life on a daily basis, what to wear, what activity she can do, when she can do the self-care. She has to wrap her arm, wear a compression sleeve when flying, undergo time-consuming massage therapy, spends a lot of time with her arm elevated, in a finger wrap. She hides her hand or her glove, doesn’t want to explain it. It affects self-image, work, and recreation. No one in the medical profession owns the problem or seems very concerned about it. Insurance companies sometimes don’t even pay for the specialized physical therapy to treat it and even finding a knowledgeable therapist can be daunting. Although my first surgery resulted in a positive sentinel node at the final pathology, I declined a second surgery to remove my axillary nodes due to the risk of lymphedema, because I have chosen all of the available treatment options. Removing those nodes changes nothing. Despite my serious personal concern about lymphedema, I was still advised by the doctors to undergo the second surgery because it is the “standard of care.” I choose, instead, to do radiation to the axilla, as I’m doing radiation to the breast daily for 6 1/2 weeks, but lymphedema is also a complication of radiation therapy, albeit a smaller risk. Ironically, my biggest fear was chemotherapy, and although I’ve lost my hair, had several major issues and once landed in the emergency room due to side effects, I am halfway through that treatment, had many more good days than bad and feel hopeful that the side effects are temporary. When I researched the drug Arimidex, which was recommended for my future hormone therapy, I saw stories of crippling bone pain, loss of libido, extreme night sweats, depression, anxiety, insomnia, weight gain, cough and hair loss, sometimes permanent. Of course, not all patients have side effects, but those who did told me that doctors did not treat these problems, especially the loss of libido, as important quality of life issues. Although these are serious and frustrating issues, they are not priorities with doctors as long as the cancer is gone. Many survivors are also willing to endure these awful indignities and side effects as long as cancer does not return. Fear is a huge motivator. I don’t want to discourage cancer patients from getting treatment, but they need to be pro-active in educating the medical profession that these side effects are not minor inconveniences, they have a huge impact on daily life. My main worry is not recurrence; it’s my quality of life. I’m not interested in fighting for my life; I’m interested in living it. It’s my life, my body and my choice. Survival is definitely the goal, but living a high quality, full life should be the ultimate goal, and we should not settle for less. __________________________________________________________________ November 14, 2008 Globe and Mail, Canada KIRK MAKIN JUSTICE REPORTER JUSTICE: SUPREME COURT OF CANADA Top court refuses to hear case of woman with rare leg injury Seven years after a 29-year-old Toronto woman was hit by a car while soliciting donations to fight cystic fibrosis, the court system has closed its doors to her plea for sympathy. "It's quite upsetting, because my injuries are permanent," Andrea Lazare said yesterday, hours after the Supreme Court of Canada refused to hear her appeal. The decision ended Ms. Lazare's last hope of setting money aside in case her rare leg injury renders her unable to work. Ms. Lazare's future was sent into a tailspin in 2005, when a jury awarded her "zero" dollars for lost future income in a lawsuit against the driver who hit her, Danica Harvey. The conditions that resulted from her many injuries included lymphedema in her left leg - a painful, lifelong condition in which fluid gathers and must be drained regularly. Ms. Lazare must use a mechanized pump for eight to 10 hours each night on her immobilized leg. She wears compression stockings during the day and has fluids drained weekly. The jury awarded her a total of $350,000 in general damages - an amount that Ms. Lazare's lawyer, Jeffrey Strype, said falls far short when it comes to alleviating a lifetime of pain that may eventually include elephantiasis, skin breakdown, tumours - even death. "It's shocking, because this girl is deteriorating rapidly," Mr. Strype said yesterday. "She is really, really concerned that she is going to run out of money for her machines and treatment. If that happens, she will be in horrific pain. Yet, legally, we have been shut out." Ms. Lazare's appeal stands as a classic instance of jurisprudence and cold-hearted legal principle clashing with a poignant story of human suffering. In a 2-1 decision, the Ontario Court of Appeal ruled last year that appellate judges can intervene only when a jury has acted "in violation of its duty." "Absent good reason, litigants are not entitled to two kicks at the can," said Madam Justice Susan Lang and Mr. Justice Russell Juriansz. But in a passionate dissent, Mr. Justice John Laskin branded the jury's decision "unfathomable." The medical evidence had shown overwhelmingly that Ms. Lazare may face lost future earnings of up to $2.8- million, he said, and denying her compensation was "both unjust and unreasonable. "To now say there is no real and substantial possibility that she will suffer a loss of income in the future defies reason," Judge Laskin said. "Perhaps it was unduly influenced by Ms. Lazare's own courage, determination, and refusal to complain in the face of her adversity." A fourth-year university student, Ms. Lazare was knocked unconscious as she stood on a road median soliciting donations. After a long recovery period, she obtained a job with the Toronto Blue Jays. She has progressed rapidly in the team's corporate sales department. However, she often has to leave work early because of pain. Sports and travel are difficult or impossible, and pregnancy would carry significant risks. In addition, the special apparatus she uses every night to force fluid from her swollen leg is expensive and must be replaced regularly. Judge Laskin said he had no doubt that her condition has "no known cure and potentially fatal complications. ... The degeneration will become more pronounced if she has a job that requires a lot of walking or standing, if she gets pregnant, or even if she gets a minor skin infection from a mosquito bite on her leg." To win an award for future income, Ms. Lazare needed to convince the jurors that there was "a real and substantial possibility" of her future loss of income. However, due to the rarity of her condition, medical evidence was imprecise. One of her managers also remarked on Ms. Lazare's apparent ability to function well at work. Mr. Strype said yesterday that, due to arcane rules of evidence, the jury was not permitted to hear a great deal of information about what Ms. Lazare can expect in terms of financial help from her insurer - information that he said would likely have elevated the award. "The jury in Canada today is so bereft of information that asking six people to translate injury into damages is becoming impossible," Mr. Strype said. "We seem to be firmly entrenched in the 12th century. She has used all the accident-benefit money available to her. We are now down to hoping that her accident-benefits insurer will assist her." Ms. Lazare said that she has to soldier on. "I could wake up every morning and not get out of bed, but I feel like I am a fairly optimistic person," she said. "I try to see that there is a reason this has happened to me. But I have a degenerative disease. I want to be able to do anything I can to take care of myself." ________________________________________________________________ November 14, 2008 Point Pleasant Register, WV By Hope Roush Training planned for ‘Reach to Recovery’ volunteers POINT PLEASANT — For more than 35 years, the American Cancer Society Reach to Recovery program has helped people cope with their breast cancer experience. This experience begins when someone is faced with the possibility of a breast cancer diagnosis and continues throughout the entire period that breast cancer remains a personal concern. When people first find out they have breast cancer, they often feel overwhelmed, vulnerable and alone. While under this stress, many people also must learn about and try to understand complex medical treatments and then choose the best one. Talking with a specially trained Reach to Recovery volunteer at this time can give a measure of comfort and an opportunity for emotional grounding and informed decision-making. Volunteers are breast cancer survivors who give patients and family members an opportunity to express feelings, talk about fears and concerns and ask questions of someone who is knowledgeable and level-headed. Most importantly, Reach to Recovery volunteers offer understanding, support and hope because they themselves have survived breast cancer and gone on to live normal, productive lives. According to Kristy Fidler, community manager of the South Atlantic Division of the American Cancer Society, cancer patients relate more to Reach to Recovery volunteers. “Reach to Recovery volunteers are all breast cancer survivors themselves, and when a woman is newly diagnosed (with breast cancer) and they see survivors two, three or 10 years out, they have inspiration and hope,” Fidler said. “(Reach to Recovery volunteers) are trained to let (patients) know what resources are available and let them understand what they may face.” Through face-to-face visits or by phone, Reach to Recovery volunteers give support for people recently diagnosed with breast cancer; people facing a possible diagnosis of breast cancer; those interested in or who have undergone a lumpectomy or mastectomy; those considering breast reconstruction; those who have lymphedema; those who are undergoing or who have completed treatment such as chemotherapy and radiation therapy; and people facing breast cancer recurrence or metastasis. According to Fidler, all volunteers complete a three- to four-hour training course. They are trained to give support and up-to-date information, including literature for spouses, children, friends and other loved ones. Volunteers also can provide breast cancer patients with a temporary breast form and information on types of permanent prostheses, as well as lists of where those items are available within a patient’s community. “We have two volunteers in Mason County who are trained, and we are trying to get more volunteers to (help) those newly diagnosed with breast cancer,” Fidler said. She added that many breast cancer survivors choose to become a volunteer because they want to help others battle the same thing they went through. Fidler described the Reach to Recovery volunteers as having more of an impact on women diagnosed with breast cancer because of their experiences. “As a member (of the American Cancer Society) I can tell you things, but I’ve never had breast cancer,” she said. “It is much more valuable when a survivor says ‘this really helps.’” Fidler also emphasized that the volunteers do not give medical advice, but are simply a support system to help women cope with their diagnosis. She encouraged area survivors to become volunteers. “If (survivors) have really been looking for a way to share their experience and give others hope, then (Reach to Recovery) is a good way,” Fidler said. The American Cancer Society will host Reach to Recovery training 5:30-8:30 p.m. Monday at CAMC Teays Valley, located at 1400 Hospital Dr. in Hurricane. Local breast cancer survivors who are one- year post treatment are encouraged to attend. Fidler also encouraged those who would like to volunteer in other areas to call the local American Cancer Society office at 304-523-7989. ___________________________________________________ November 14, 2008 Lawyers and Settlements By Jane Mundy Unum Arbitrarily says "You're Done" Syracuse, NY: Leigh was involved in a horrific accident and collected disability payments from Unum Provident (now called Unum or First Unum). Two years later, Unum's independent medical examiner determined that Leigh was no longer disabled and cut her off long term disability benefits on Christmas Eve, just to add insult to injury. "Months later I had a lawyer help with an appeal (he did it pro bono) and Unum had to reinstate me," Leigh says. But it was short-lived and she was cut off again. "After about two more years Unum again told me that they were no longer going to continue my disability payments and decided they were going to 'buy me out' with a lump sum payment," says Leigh. "I don't remember the exact amount but it didn't last long. "It gets to a point where they just don't want to pay you anymore so they offer to buy you out," says Leigh, "and they told me that I didn't have a choice. At this time I was in the process of getting social security disability and the lawyer I was talking to at the time explained that if I got social security benefits I would have to pay some of it to Unum. He advised me to close my case so Unum wouldn't have access to my social security benefits. I took his advice. The Accident This is what happened: In 1989 I was working as a teacher when I was involved in a motorcycle accident with my fiancé. A man in a pickup truck rolled through a stop sign, right into our path. My fiancé was killed instantly, 12 days before our wedding. I had a compound fracture of my right femur, a break of my tibia and fibula on the right leg, and a shattered area just below my knee. My knee was displaced and I have donor bone at the shattered site. I also had a broken pelvis and a huge laceration in my left leg." And of course, Leigh had more than physical problems to deal with. " I was a wreck and haven't been able to work full time since the accident." Leigh was sent to numerous "independent" medical examiners. "During one IME (independent medical examination), this doctor gave me a comprehensive evaluation to see what my disabilities were," says Leigh." I had to walk up and down stairs and put shapes into things. He said I was still disabled but 'de- conditioned' which meant that I had not done anything in so long I was losing muscle function. He suggested I go to occupational therapy but they didn't follow up… "My issue is that 19 years later, I am still unable to consistently work full time (and probably no longer part-time at any meaningful job). I was making just under $1200 when I first received my long term disability benefits. I had a job I was doing from home (medical transcription) and got benefits through that job, but I could no longer perform that work either. My benefits then were a little over $800, if I remember correctly. Now, I get social security benefits that total $725--after Medicare. I believe I should still be receiving Unum long term disability. It frustrates me to know that I could be getting almost $500 a month more than I am, if I had not been treated unethically by this bad-faith insurance company all those years ago. I now have fibromyalgia and plenty of osteoarthritis. I am still having new complications of my injuries, such as lymphedema in my legs. My Unum life insurance should never have been cut off. If I continue to be disabled and cannot work, I am entitled to get long term disability with Unum and if necessary, for the rest of my life. After all, social security approved me immediately. I calculate that Unum owes me $300 per month for the past 15 years, plus interest. As a disabled person, I still want to fight their decision." ___________________________________________________ November 16, 2008 Chico Enterprise-Record Daily Planner THERAPEUTIC DANCE: 6-7 p.m. Healing through movement and dance; exercise program helps regain range of motion, increase flexibility, reduce swelling from Lymphedema, promote positive self- image. Any age, fitness level. $10 fee first class. Enloe Cancer Center Conference Room, 251 Cohasset Road. Register, 332-3855. ____________________________________________________ November 17, 2008 Dubuque Telegraph Herald Health briefsPhysical therapists to discuss lymphedema Physical therapists Amy Greener and Amy Brooner will discuss "Lymphedema Following Cancer" at 10 a.m., Wednesday, Nov. 19, at The Finley Babka Wellness Center, 1550 University Ave. Participants will be made aware of the symptoms of lymphedema and the importance of early detection. The cost is $5. Register by calling 877-242-8899. __________________________________________________________________________ November 17, 2008 Toledo Free PressWritten by Brandi Barhite Event to focus on breast cancer effect Breast cancer puts you at risk for lymphedema. But some people don’t know much about the painful side effect or that they are at risk for it. The Victory Center and Renee’s Survivor Shop want to change that. They will host a Lymphedema Health Fair from 10 a.m. to 2 p.m. Nov. 3 at The Victory Center, 5532 W. Central Ave., Toledo. It is free and open to anyone. Renee Schick, owner of Renee’s Survivor Shop, 5401 Secor Road, has had problems with lymphedema, a condition of localized fluid retention. The five-year breast cancer survivor said lymphedema generally occurs because of poorly developed or missing lymph nodes, especially lymph node removal due to breast cancer. Radiation increases the risk. Schick, 43, had 17 lymph nodes removed. Bodies have a network of lymph nodes and lymph vessels that carry lymph fluid. The lymph fluid contains white blood cells that help fight infections. “I don’t know if all doctors are telling their patients,” Schick said of the potential of developing lymphedema. The lymphatic system is known as the body’s second circular system and collects and filters the interstitial fluid of the body. Those who develop lymphedema may experience swelling of the limbs, fingers and puffiness. “It’s not just breast cancer survivors who can develop this,” Schick said. “There are lymph nodes in the lower parts of the body.” Kelly Brooks, program director at The Victory Center, said people do not always get good information about lymphedema. Special guests at the fair will include Dr. Anita Leininger and breast cancer survivor Barb Ulrich. Attendees will be able to talk to professionals, try out lymphedema products, see lymphatic massage demonstrations and learn how to try to prevent lymphedema. Leininger said it is important to educate. Cancer patients should know the risks and what precautions to take. Getting an evaluation is key, she said. “The risk never goes away,” Brooks said. “It’s not like if you don’t develop it, you won’t later. There are a number of ways to manage the condition, but the goal is to get the right information and treatment as early as possible.” One prevention strategy is wearing a compression sleeve when flying in an airplane. Flying is a problem because of being immobile for so long, she said. Those at risk could fly several times before developing a problem. “When you fly, wear a sleeve or garment even if you don’t have lymphedema,” Brooks said. The Victory Center supports and educates cancer patients through individual and group programs. Renee’s Survivor Shop offers products, gifts and services for cancer patients. The two often work together and after hosting a small program about lymphedema last year wanted to expand it. “If we have a good turnout, I don’t see why we wouldn’t have it every year because every year we have new survivors,” Schick said. ___________________________________________________________________________ November 18, 2008 Cancer Consultants.com Daily Cancer NewsThe 2008 Annual American Society of Clinical Oncology Breast Cancer Symposium The 2008 annual American Society of Clinical Oncology's (ASCO) Breast Cancer Symposium, held this year on September 5-7 in Washington, DC, delivered results encompassing advancements in screening, diagnosis, treatment, supportive care, and individualized therapies for patients with breast cancer. This year's meeting was jointly sponsored by ASCO, the American Society of Breast Disease, the American Society of Breast Surgeons, the American Society for Therapeutic Radiology and Oncology, the National Consortium of Breast Centers, Inc., and the Society of Surgical Oncology. The event brought together world-renowned clinicians and researchers who are dedicated to improving outcomes for those diagnosed with breast cancer. Metastatic and Recurrent Disease Survival Over the past decade, patients with metastatic breast cancer have seen a significant increase in the agents available to them for therapy, including targeted agents such as Herceptin® (trastuzumab) and Tykerb® (lapatinib), the new aromatase agents, novel chemotherapy agents, and supportive care measures. However, it has not been well established whether survival rates for these patients parallel the increase in novel therapeutic measures. To evaluate changes in survival over the decades during which newer therapeutic options have become available for patients with metastatic breast cancer, researchers from the city of Hope Comprehensive Cancer Center in Duarte, California, conducted a retrospective analysis comparing survival rates before and after the new drug era (1985 to 1994 and 1995 to 2005, respectively).[1] The study included patients with metastatic breast cancer who were treated at their center between 1985 and 2005; 199 of whom were diagnosed between 1985 to 1994 and 159 of whom were diagnosed between 1995 to 2005. The median overall survival was improved by 2.4 years from 1985 to 1994, while the median overall survival was improved by 3.1 years between 1995 and 2005; the difference in survival between these two time periods did not reach statistical significance (P=0.26; HR=1.14). There was a suggestion that elderly patients with metastatic disease had an improvement in survival between the two time periods; however, these data need confirmation. Hormone-receptor status was not associated with any significant survival differences between the two time periods. Median overall survival for metastatic colorectal cancer had significantly improved during the same two time periods (1.2 years to 2.0 years; P<0.0001). The researchers stated that these results were against their expectations as they assumed an improvement in survival had been achieved over the decades. However, they emphasized that these data were from a single institution and perhaps greater subgroup evaluation may identify survival differences among certain groups of patients. Chemotherapy Although newer agents have arrived and been integrated into standard care for breast cancer, the use of chemotherapy and radiation remain integral in the therapeutic regimen for most patients. As such, research continues to explore different schedules, doses, and combinations of chemotherapy agents among patients with this disease.Metronomic administration of chemotherapy is an area that has been evaluated in the palliative setting for patients with breast cancer, particularly among those who are not able to tolerate significant side effects. Metronomic administration (low-dose and rapid administration) allows for lower doses of therapy to be administered without a prolonged drug-free break with lower toxicities. Laboratory analysis has indicated that metronomic administration may enhance apoptotic and anti-angiogenic effects of therapy; trials continue to evaluate the efficacy of this approach. Researchers from the University of Ottowa recently conducted a clinical trial to further evaluate the use of metronomic chemotherapy among patients with anthracycline-resistant breast cancer.[2] As there is no consensus statement on the treatment of anthracycline-resistant breast cancer, trials evaluating this group of patients are ongoing in an attempt to identify optimal therapies for specific subsets of these patients. This uncontrolled trial included 47 patients with HER2-negative, anthracycline-resistant, or refractory locally advanced or metastatic breast cancer, 38 of whom were evaluable for responses. Initial treatment consisted of weekly low-dose Taxotere® (docetaxel) 15 mg/m2, plus daily Xeloda® (capecitabine) 1,250 mg, and twice-daily Celebrex® (celecoxib) 200 mg. After four weeks, doses of Taxotere could be increased to 20 mg/m2 weekly if patients did not experience grades III/IV neutropenia, and at eight weeks escalation of Taxotere to 25 mg/m2 was allowed. Approximately three-fourths of patients were administered the first dose escalation, and approximately one-third were administered the second dose escalation of Taxotere. The primary endpoint of the trial was clinical benefit, defined as responses or disease stabilization for at least six months. Clinical benefit (disease stabilization plus responses) was achieved in over 40% of patients. Over one-third of patients achieved objective responses. 8% of patients achieved disease stabilization beyond six months. The addition of Celebrex did not appear to provide any benefit. Less than 10% of patients had grades III-IV hematologic toxicity, while no patients experienced grades III-IV non-hematologic toxicity. Median time to progression for all evaluable patients was 15 weeks, while median time to progression among patients who achieved a clinical benefit was 32 weeks. The lead author of the trial, Dr. Young from the University of Ottowa, stated: “Treatment given in this metronomic fashion is associated with significant anticancer activity and was well tolerated in this study. The efficacy of this regimen may be underestimated, as our study design involved a two-step escalation of docetaxel. It is possible that some patients experienced early progression prior to receiving an adequate dose of this agent….This particular dosing schedule for docetaxel and oral capecitabine should be examined further in clinical studies involving combination therapy with novel targeted therapies.” Ixempra™ (ixabepilone), approved in October 2007, is the first epothilone approved for clinical use in the treatment of cancer. Its approval was based on the “046” randomized clinical trial (n=752) comparing Xeloda (C) to Xeloda plus Ixempra (I+C) in anthracycline- and taxane-refractory metastatic breast cancer.[3] Results from the “046” trial significantly favored the I+C arm in terms of prolonged progression-free survival compared with C only. Dr. Gabriel Hortobagyi presented results at this year's breast cancer meeting that included a combined analysis of the “046” trial and the “048” trial, a second, larger randomized trial (n=1221) comparing I+C to C in anthracycline- and taxane-refractory, metastatic breast cancer.[4] The combined analysis confirmed a significant improvement in progression-free survival in the I+C arm, as well as a trend in overall survival for I+C (HR, 0.85; 95% CI, 0.75-0.98; P=0.231). The researchers also noted that I+C has a manageable safety profile. At this juncture Ixempra presents a novel chemotherapy agent for this difficult-to-treat patient population; however, due to a lack of data at present, physicians must employ its use based on the profile of the individual patient (i.e., single-agent sequential management versus combination therapy). ER/PR/HER2 Status Identification of the estrogen and progesterone receptors, as well as the HER2 pathway, has provided perhaps some of the greatest breakthroughs leading to individualized treatment for cancer. Breast cancer patients have derived overwhelming benefit through the understanding of these biologic pathways as corresponding therapies have emerged targeting cellular components specific to each pathway. However, new findings continue to emerge that reinforce the fact that all biologic elements intrinsically possess intricate and ever-changing details that require perseverance in research to gain a greater understanding of their complexity. As there often remains discordance between metachronous metastatic sites and primary tumor characteristics in terms of ER/PR/HER2 status, confirmation through biopsy of metastasis is often the recommendation and practice of oncologists to determine optimal treatment approaches. Dr. Alvarez and colleagues recently conducted a study to evaluate the rate of discordance between a recurrent metastatic site and the primary tumor among 961 patients with recurrent metastatic breast cancer.[5] Patients had tumor tissue available for HER2 testing from the primary tumor and/or axillary nodes and the metastatic site by fluorescent in situ hybridization (FISH), with a median time from original diagnosis to metastasis being 33 months. No patient had received prior adjuvant Herceptin. Ninety-four percent of cases had concordant HER2 results between the metastatic and primary tumors. Of the 8% with discordant results, all patients had HER2-positive primary tumors and HER2-negative metastatic tumors. A study was conducted by Dr. Simmons and colleagues in which HER2 status as well as ER and PR status were evaluated in both metastatic and primary tumors among 29 patients with metastatic breast cancer.[6] 10% of patients had benign disease on biopsy of suspicious metastases. One patient had a low-grade lymphoma at the site of suspicious metastasis. Two patients with HER2-negative primary disease had HER2-positive metastases. 40% of patients had discordance between primary and metastatic sites in terms of hormone receptor status. Results from biopsies of metastatic sites directly affected treatment change in 20% of patients (p=0.002). Taken together, the results of these studies indicate that a biopsy of metastasis appears appropriate so that treatment aimed at the biologic characteristics of the metastatic site(s), which are often in contrast with those of the primary tumor, can be employed to provide an effective overall systemic approach. However, the researchers cautioned that a biopsy of brain metastasis among all patients with this site of metastasis does not appear warranted at this time. The reasoning behind this is the difficulty in obtaining a biopsy through the cranium and the lack of data indicating a high rate of discordance in terms of biologic characteristics between brain metastasis and a primary breast tumor. Research is ongoing to further evaluate this issue. To further illustrate the complexities of biologic pathways, it appears that a significant portion of primary HER2-positive tumors will convert to HER2-negative tumors following an incomplete pathologic complete response to Herceptin. Dr. Mittendorf and colleagues from the University of Texas M. D. Anderson Cancer Center conducted a study including 143 patients with HER2-positive (as ascertained by FISH) breast cancer who underwent neoadjuvant therapy with Herceptin, a taxane, and an anthracycline.[7] Following therapy, half of the patients achieved a complete pathologic response defined as no evidence of disease in the breast or axilla. Tissue specimens for patients who did not achieve a complete response were available for 23 patients pre- and post-therapy. Post-treatment testing of tissue specimens revealed that 30.4% were no longer HER2-positive. Dr. Mittendorf stated: “We don't yet know, on a molecular level, what causes tumors to change” and there were no other identifiable changes in the tumor cells. Although these results may need additional supportive results, it appears that patients with HER2-positive tumors who do not achieve a complete pathologic response with Herceptin may derive benefit from a post-therapy biopsy to determine subsequent HER2 status. Dr. Mittendorf also stated that optimal adjuvant regimens for this subgroup of patients need evaluation. Dr. Subramaniam and colleagues of Georgetown University also reported on biologic changes that may occur among women with hormone-positive breast cancers.[8] These researchers conducted a clinical trial evaluating the effectiveness of Nexavar® (sorafenib) in addition to Arimidex® (anastrozole) among women with hormone-positive breast cancer who progressed or recurred following treatment with Arimidex. As a single agent, Nexavar is considered inactive as therapy for breast cancer. However, Nexavar targets several pathways, including the ras-raf-MAPK pathway, which is implicated in resistance to therapy. Therefore, the trial evaluated the combination of Nexavar and Arimidex to determine if Nexavar could help overcome resistance to Arimidex among 27 postmenopausal patients with metastatic hormone-positive breast cancer that had stopped responding to endocrine therapy. Patients received Nexavar 400 mg twice daily plus standard doses of Arimidex. 26.08% of patients achieved a partial response or disease stabilization lasting more than six months. A declining level of circulating endothelial cells during the initial week of therapy was associated with response to the treatment combination. The researchers of the study concluded that Nexavar may help to overcome resistance to endocrine therapy among postmenopausal women with hormone-positive breast cancer; results that may provide far-reaching implications into understanding how to overcome resistance of other types of therapies in several types of cancers. Early Breast Cancer Different adjuvant chemotherapy, hormone, and combination regimens continue to be compared in early breast cancer. As treatment is becoming more individualized, several studies are underway in an attempt to understand which patient and disease characteristics will influence outcomes of specific therapies. Oncotype DX®, the reverse transcription polymerase chain reaction (RT-PCR) 21-gene assay, represents a major milestone in the progress of individualized therapy. Oncotype DX is a clinically validated test that quantitatively predicts the likelihood of breast cancer recurrence in women with newly diagnosed, early-stage invasive breast cancer and assesses the benefit these patients will achieve from chemotherapy. Oncotype DX has been included in the NCCN and ASCO guidelines for patients with estrogen-receptor positive early breast cancer to help guide treatment decisions.[9],[10] The 21-gene assay has also demonstrated the ability to determine ER/PR status, results that are now included as part of the assay’s results.[11],[12] More recently, researchers have been evaluating the accuracy of Oncotype DX in determining HER2 status. It is now recommended that all breast cancer patients be tested for HER2 status before beginning treatment, as agents targeted against HER2 are available and tend to improve outcomes for patients overexpressing HER2. Standard testing for HER2 includes immunohistochemistry (IHC) and fluorescence-in-situ hybridization (FISH) testing. Researchers recently conducted two studies to explore the accuracy of Oncotype DX in establishing HER status when compared with standard IHC or FISH testing among breast cancer patients. The first study analyzed data from 755 patients who were enrolled in the Intergroup study E2197. These patients had Stage I-III breast cancer with 0-3 three positive lymph nodes; HER2 status was compared between central IHC and central RT-PCR using a panel of 371 genes including the 21 in Oncotype DX.[13] The concordance rate of HER2-positive status between central IHC and central RT-PCR was 95% (95% CI, 92%, 96%). The second study evaluated data from a previous clinical trial conducted by researchers from Kaiser Permanente, the University of California-San Francisco, and PhenoPath, Inc.[14] The study included 568 patients and compared HER2 status as tested by FISH or Oncotype DX testing. Twelve percent of patients were HER-2 positive by Oncotype DX and 11% by FISH. There was a 97% overall concordance (95% CI, 96%, 99%) between the two methods of testing. The researchers concluded that Oncotype DX possesses the ability to accurately determine HER2 status when compared to standard testing among breast cancer patients. As of the end of September, 2008, Oncotype DX now includes ER, PR and HER2 status in all generated reports, allowing for a single test to provide results that previously required several individual tests. TOP2A Deletions and amplifications within the topoisomerase II alpha gene (TOP2A) have emerged as a predictor of an improved response to anthracycline-based therapy.[15] Gene alterations within TOP2A are rare in hormone receptor-positive, HER2-normal cancer, while TOP2A is co amplified in approximately 65% of HER2-positive tumors. The TOP2A gene continues to be studied in trials as it appears to be an upcoming and important potential variable upon which to guide therapy. The Eastern Cooperative Oncology Group (ECOG) conducted a study to further examine TOP2A gene alterations (amplifications or deletions) among hormone-positive, HER2-normal disease.[16] Patients received therapy with either AC (doxorubicin, cyclophosphamide) or AT (doxorubicin, docetaxel). A computer model evaluating TOP2A expression plus the therapeutic regimen demonstrated that TOP2A expression was significantly associated with an increased risk of recurrence, even when adjusted for age, nodal status, tumor size, and grade of tumor. Patients with a low TOP2A expression trended toward an improved outcome with AC, while those with a high TOP2A expression trended toward a favored outcome with AT. Although these results themselves will not change clinical practices, they demonstrate that TOP2A continues to remain a potentially major player in deciding treatment for breast cancer. Prophylactic Mastectomy It has been well established that younger women with breast cancer tend to have more aggressive disease than their older counterparts. Therefore, younger patients may take a more aggressive approach to reducing the risk of a recurrence or second primary, such as a contralateral prophylactic mastectomy among patients with early breast cancer. Although a prophylactic contralateral mastectomy drastically reduces the risk of a recurrence in the contralateral breast, its affect on survival is not well known. Researchers from the University of Texas M. D. Anderson Cancer Center in Houston, Texas, recently conducted a clinical study to evaluate the association between survival and prophylactic contralateral mastectomies among women with early breast cancer.[17] The study was a retrospective review of the Surveillance, Epidemiology, and End Results (SEER) database, including over 80,000 women with Stages I-III breast cancer diagnosed from January 1998 through December 2003. All patients were diagnosed with unilateral cancer, and nearly 8% underwent a contralateral prophylactic mastectomy. In an unadjusted comparison, contralateral prophylactic mastectomy was found to significantly improve survival (HR=0.69, P<0.001). When adjusting for variables, the following associations were demonstrated: No survival benefit was demonstrated among estrogen receptor (ER)-positive patients who underwent a prophylactic contralateral mastectomy. Among ER-negative patients, no survival benefit was demonstrated among patients with Stage III disease or older patients, regardless of stage. Younger patients (ages 18 to 49) with ER-negative Stage I or II disease had a significantly reduced risk of death with a prophylactic contralateral mastectomy (P=0.03). The survival benefit achieved by the surgery among younger, ER-negative patients appeared to be almost exclusively due to a reduction in the development of contralateral breast cancers. The researchers stated that although a prophylactic contralateral mastectomy may appear to be a radical treatment choice, younger patients with Stages I/II, ER-negative disease may derive a significant benefit from the procedure. Neoadjuvant Therapy Another treatment issue in early breast cancer that continues to be evaluated is neoadjuvant therapy, particularly in larger tumors confined to the breast. As neoadjuvant therapy can shrink the tumor pre-operatively, allowing for breast-conserving surgery in a greater number of women, researchers attempt to identify the largest size and tumor characteristics that can still benefit from neoadjuvant therapy. Researchers from Europe conducted the European Cooperative Trial of Operable Breast Cancer that included 1,355 patients with breast cancers greater than 2 cm.[18] Patients were randomized to either neoadjuvant or adjuvant therapy, with the primary endpoints being relapse-free, distant relapse-free, and overall survival as well as the rate of local recurrences. Twenty percent of patients had tumors larger than 4 cm; approximately 55% were 50 years or older; and nearly 70% had hormone receptor-positive disease. Morbidity Perhaps breast-conserving therapy achieved with neoadjuvant therapy plays an even larger role than cosmesis and sexuality; also affecting long-term upper-body morbidity among patients undergoing surgery for breast cancer. Researchers from Australia conducted a study to evaluate function-limiting upper-body morbidity among 258 breast cancer patients who underwent surgery for their disease.[19] Assessment of the upper-body symptoms and their impact on function was assessed at six months following diagnosis and every three months to 18 months and included factors such as upper-body strength and endurance, hand grip, flexibility and range of motion, and score on the Disability of the Arm, Shoulder, and Hand questionnaire. Numbness and swelling remained the most common symptoms at each assessment, ranging from 20% to 30%, while pain, tingling, weakness, stiffness, and poor range of motion were also common complaints. Symptoms became less common the longer patients were from surgery. At 18 months approximately 40% of patients still complained of at least two moderate to severe symptoms. 66% of patients with lymphedema reported upper-body symptoms at six months compared with 44% without lymphedema. The researchers stated that upper-body morbidity plays a long-term role in a significant portion of women undergoing surgery for breast cancer, even among those without lymphedema. Long-term morbidity issues are gaining more attention as cancer survivors are living longer, and the understanding of ways in which to minimize these morbidities is becoming paramount to maintaining a patient’s quality of life. Looking Forward Although presentations from this year’s breast ASCO may not have delivered immediate practice-changing results, understanding of the biology of breast cancer, gathering information regarding specific genes and mutations and their effects on the development and course of a disease, identification of subgroups of patients who respond differently to therapies, and quality-of-life issues are all invaluable in understanding the complete picture of how to optimally treat breast cancer patients. The theme of breast cancer therapy continues towards a more individualized approach with tests such as OncotypeDX, testing of TOP2A, potential ER/PR/HER2 discordance between primary and metastatic sites, and overcoming resistance. __________________________________________________________________________ November 18, 2008 Reuters Women may ignore cancer-related lymphedema: survey NEW YORK (Reuters Health) - Many women who experience abnormal swelling of the arm or shoulder area following treatment for breast cancer -- a bothersome condition called lymphedema -- suffer in silence, a new survey indicate. Others don't follow the treatment advice of their doctor or use "alternative" treatments, which they may not discuss with their doctors. Lymphedema is a common, chronic condition that often develops after breast surgery involving removal or damage to the lymph nods in the armpit. It occurs when excess lymphatic fluid accumulates, leading to swelling, rash, redness and blistering that causes tenderness, numbness, or aching in the arm, chest wall and breast. "Lymphedema has a profound impact on health and well-being, but often goes undiagnosed and untreated by physicians and patients," said Jane Armer in a statement. "Understanding the ways that people self-manage the chronic symptoms of lymphedema is essential to facilitate an improvement in the use of treatments and quality of life." Armer, at the University of Missouri-Columbia and the Ellis Fischel Cancer Center, and colleagues asked 40 breast cancer survivors with lymphedema how they manage the condition and discovered that the most common strategy was to not treat the symptoms at all. For 12 out of 14 symptoms, patients reported taking no action 29 percent to 65 percent of the time, the researchers found. "I was perhaps most interested in the finding that the most frequent symptom management response was 'no action'," Armer told Reuters Health. "This informs me as both a nurse and a researcher that more needs to be done in understanding effective management approaches for lymphedema and educating patients and health professionals about available management alternatives." For those that did do something about their lymphedema, most often (about 47 percent of the time) they used doctor-recommended techniques -- typically non-drug approaches like simple lymph node drainage and wearing compression garments. Others turned to drug treatments such as antibiotics and over-the-counter painkillers, while still others favored "lay symptom management" -- strategies not recommended by healthcare providers but which include common sense, folk, complementary or alternative methods -- like resting, drinking water, or applying heat or ice to combat arm swelling. According to Armer, patients increasingly are using these types of therapies and most don't talk to their doctor about it. "It is essential that women communicate with their health care providers (both primary care providers and specialists) about the treatment alternatives they have sought and are using for their health conditions. Only in this way can their self- management and overall health be optimized," Armer said. "Two-way communication between the patient and all members of the health care team is vital." ___________________________________________________________________________ November 18, 2008 Enterprise-Record Daily Planner: November 19 THERAPEUTIC MOVEMENT: 9-10 a.m. Healing class for women can be done sitting or standing. Helps regain range of motion, increase flexibility, reduce swelling from Lymphedema, promote positive self-image. Any age, fitness level. $10 fee first class. Enloe Cancer Center Conference Room, 251 Cohasset Road. Register, 332- 3855. ___________________________________________________________________________ November 19, 2008 Estacada NewsBy Tamara Nielsen Good vibes ingredient for healthy livingBody responds to sound vibrations The Beach Boys had something going on with their song "Good Vibrations" in the 1960s. Have you ever felt good or bad “vibes” from someone or something? Recently, we have had to endure the onslaught of political ads and negative attacks. Everyone has been looking forward to having the television back to normal. We are at last free from these attacks to our peace of mind, but just around the corner, we will soon be hit with the commercialism of the holiday season. We have doomsday predictions of the economy, the changing political climate and the daily reports of the rising crime rate; we are literally assaulted with negative vibrations constantly, every day. We can either become a bit calloused in order to maintain our own sense of peacefulness, respond with our own negativity, or, as an alternative, perhaps we can add some good vibrations to the earth. It has been shown that when a musical instrument tunes to a certain chord or tone, the human body also tunes to that note or vibration. Humans are made up of 90 percent water, and we literally “flow” from one moment to the next. If you have you ever seen a pool of water that has had a rock thrown into it and watched the ripple effect that takes place you cannot deny that there is a definite “ripple effect” that we feel when we are exposed to vibrations, either negative or positive. Our hearing is made up of our ears receiving vibrations and turning them into sound, which, in turn, travels through our bodies. These frequencies, or vibrations, can include the sound of a flowing stream, the sound of your mother’s voice, the songs of whales, the beat of classical music, a favorite hymn, or even Christmas carols. Basically, the different parts of our physical, emotional, mental and spiritual-being resonate to various frequencies of vibration. There are many fields of healing cropping up lately regarding vibrational therapies. There are tuning fork vibration therapies, healing energies, sound frequency therapies, and even four-year degrees in musical therapy, just to name a few. These newly expanding therapy fields show us something that we already know. If we consciously engage our senses in good vibrations on a regular basis, we can help to heal trauma and restore balance in our lives. Vibrations can be made up of constant loud noises, negative words or pictures that make up a great deal of our television shows and ads, or, they can also be made up of soothing music, a smile and a laugh, a certain group of words that we hear, or a tone of voice. We can either let the negative vibrations sink in and attack us, or set ourselves apart from the “ripple effect” of negativity. What will you do? Will you hum a tune, sing in the shower? Take a few minutes each day to add some “good vibes” to your day, and to the world around you. It can only help. (Tamara Nielson is a licensed massage therapist who operates the Oregon Massage and Lymphedema Clinic located at 366 N. Broadway St., Suite 210. For more information, call (503) 630-4776.) __________________________________________________________________________ November 19, 2008 Independent Press In the TownsTalk at Pathways on lymphedema SUMMIT -- From 7 to 8:45 p.m. on Thursday, Nov. 20, Kathleen Francis, MD, of Livingston will discuss the risk factors for lymphedema following breast surgery. She will also discuss treatment strategies and ways to reduce the impact of lymphedema. Dr. Francis will lecture at The Connection for Women and Families, 79 Maple St. Her presentation is sponsored by Pathways, a program of The Connection for Women and Families, that provides educational resources and ongoing support groups for women living with cancer. Lockey Maisonneuve, a personal trainer and cancer survivor, will discuss how to increase flexibility and muscle mass with the goal of getting body confidence back after treatment. Ms. Maisonneuve teaches a fitness class at The Connection for any woman who has undergone cancer treatment. Register to attend. Call The Connection at 908-273-4242, ext. 154. ___________________________________________________________________________ November 19, 2008 Surrey LeaderBy Christine Lyon Christmas creations Inside Dorothy Higbee’s garden-level suite is a winter wonderland. Themed wreaths adorned with satin bows, lace-trimmed stockings, and garlands illuminated by tiny white lights fill the entrance of her North Delta home and spill into the adjoining room. Attached to each hand-made craft is a price tag which reads Dorothy’s Renaissance in an elegant handwriting type style. Higbee’s annual craft fair runs for just three days, but she slaves over her Victorian-style and traditional high-end Christmas creations year ’round. She glances from wall to wall, admiring dozens of one-of-a-kind tree ornaments, teddy bears, centrepieces and decorative boxes. “If I had my way, this would stay up all year,” she says. She’ll have it all packed away by Valentine’s Day though, so her hobbyist husband Jim can resurrect his ever-growing model train set. Higbee has always loved crafts. Growing up, her family was quite poor so the resourceful child would rummage for scraps of ribbon and pieces of shiny cardboard discarded by nearby factories. “I’d drag it home and I would make things,” she recalls. As a schoolgirl in a Quebec convent, she picked up some craft-making skills from the resident nuns. Higbee made Victorian crafts for 20 years, selling her pieces at shows. Her fondness of 19th century décor is evident in her home, with her hand-sewn fringed lampshades and decorative crown moulding. She jokes she must have lived in the Victorian era in her past life. “I love (the time) because people made things by hand and gave them as gifts instead of going out and buying gifts,” she says. Nowadays, she focuses on her Christmas sale, attributing her love of the holiday to her birthday. Higbee turns 69 on Dec. 24, and unlike most Christmas babies, she likes sharing her birthday with the winter festivities. Higbee doesn’t have a team of helper elves – her crafts are made with her own two hands. “Everything I make has got to be from my heart and from me,” she says, explaining she once turned down a contract with upscale department store Holt Renfrew because she didn’t want to hire staff. This will be her third North Delta craft fair. After surviving breast cancer, she and her husband left Saint-Hubert, Quebec to be closer to three of their four children. “I was very, very ill in the hospital. They didn’t think I would make it,” she says. The determined patient continued to make her crafts, even while undergoing chemotherapy. She beat cancer six years ago, but has lymphedema in one arm which causes it to swell. That combined with her osteoarthritis can make intricate craftwork difficult, but her husband is happy to bend wires and lift boxes for her. Higbee’s small, low-ceilinged workshop is stacked with dozens of plastic bins filled with styrofoam balls, miniature straw hats, plastic berries, glitter, ribbons and lace. On her desk are rulers, glue, tape and about a dozen pairs of scissors. “If I make money, I take it all and I go buy more stuff,” says the passionate craft-maker. She once bought a $400 lace curtain from an antique show, but didn’t have the heart to cut up the beautiful fabric. This year, instead of spending all her profits on supplies, she plans to make a donation to the Canadian Cancer Society. She is also donating a large wreath to the silent auction at Rosemary Heights Elementary. Always willing to help others, she and her husband took in 60 foster children over 15 years after they had their own kids. Higbee had a kiln at the time and enjoyed teaching her foster kids ceramics. Now she’s passing her crafty skills onto her four grandchildren, who like to organize her cluttered workshop whenever they visit. This weekend shoppers will be able to find traditional red and green Christmas crafts, Victorian-style decorations and plenty of rust-coloured accessories – this year’s trendy hue. Items start at $4 for napkin rings and run up to $350 for her most elaborate wreath that incorporates 17 strands of beads and a miniature ice skate. Dorothy’s Renaissance runs Friday, Nov. 21 from 6-9 p.m. and Saturday, Nov. 22 and Sunday, Nov. 23 from 10 a.m.-5 p.m. at 10899 Cherry Lane, North Delta (Higbee’s suite is around back). ___________________________________________________________ November 20, 2008 SmartBriefReuters Health Women may ignore cancer-related lymphedema: survey NEW YORK (Reuters Health) - Many women who experience abnormal swelling of the arm or shoulder area following treatment for breast cancer -- a bothersome condition called lymphedema -- suffer in silence, a new survey indicate. Others don't follow the treatment advice of their doctor or use "alternative" treatments, which they may not discuss with their doctors. Lymphedema is a common, chronic condition that often develops after breast surgery involving removal or damage to the lymph nods in the armpit. It occurs when excess lymphatic fluid accumulates, leading to swelling, rash, redness and blistering that causes tenderness, numbness, or aching in the arm, chest wall and breast. "Lymphedema has a profound impact on health and well-being, but often goes undiagnosed and untreated by physicians and patients," said Jane Armer in a statement. "Understanding the ways that people self-manage the chronic symptoms of lymphedema is essential to facilitate an improvement in the use of treatments and quality of life." Armer, at the University of Missouri-Columbia and the Ellis Fischel Cancer Center, and colleagues asked 40 breast cancer survivors with lymphedema how they manage the condition and discovered that the most common strategy was to not treat the symptoms at all. For 12 out of 14 symptoms, patients reported taking no action 29 percent to 65 percent of the time, the researchers found. "I was perhaps most interested in the finding that the most frequent symptom management response was 'no action'," Armer told Reuters Health. "This informs me as both a nurse and a researcher that more needs to be done in understanding effective management approaches for lymphedema and educating patients and health professionals about available management alternatives." For those that did do something about their lymphedema, most often (about 47 percent of the time) they used doctor- recommended techniques -- typically non-drug approaches like simple lymph node drainage and wearing compression garments. Others turned to drug treatments such as antibiotics and over-the-counter painkillers, while still others favored "lay symptom management" -- strategies not recommended by healthcare providers but which include common sense, folk, complementary or alternative methods -- like resting, drinking water, or applying heat or ice to combat arm swelling. According to Armer, patients increasingly are using these types of therapies and most don't talk to their doctor about it. "It is essential that women communicate with their health care providers (both primary care providers and specialists) about the treatment alternatives they have sought and are using for their health conditions. Only in this way can their self-management and overall health be optimized," Armer said. "Two-way communication between the patient and all members of the health care team is vital." __________________________________________________________ November 20, 2008 Fall River Herald News Calendar for DecemberLymphedema education and support group Led by SAH occupational therapists specially trained in lymphedema therapy, this group addresses the needs of those living with lymphedema, an accumulation of lymphatic fluid that causes swelling in the arms and/or legs. If untreated, the limb increases in size and can interfere with healing, normal lifestyle, and function. This group is part of the monthly education and support series for patients with lymphedema and their family and friends, sponsored by Saint Anne’s Hospital Rehabilitation Services. Participants need not be patients of Saint Anne’s Hospital and may attend at any time. No charge. For more information, call 508-646-9470. __________________________________________________________ November 20, 2008 Macleans Canada The angry breast cancer survivorsWomen with post-treatment maladies find no one really wants to hear ‘downbeat’ stories Breast cancer awareness month, also known as October, came and went with scant attention paid to a new, groundbreaking book: After the Cure: The Untold Stories of Breast Cancer Survivors by Emily Abel and Saskia Subramanian. Then again, stories of women coping with life-altering, post-treatment maladies have remained “untold” for a reason. As Abel, a professor of health services and women’s studies at the University of California, and Subramanian, a sociologist at the UCLA Centre for Culture and Health, point out, the topic runs counter to the “celebratory breast cancer culture,” one filled with inspiring narratives of good health and spiritual rejuvenation. That wasn’t Abel’s experience after radiation and chemo for breast cancer in 1993. Her doctor told her recovery would take a year; to this day she still suffers from fatigue. She began noticing a “cone of silence” around the subject of health when talking with other survivors: “Everybody was supposed to say ‘I’m fine, I’m great’ and of course we were fine—those of us who survived were really very lucky and we did consider ourselves fine. But we began to realize we also had other problems that no one was paying much attention to.” After the Cure provides voice to breast cancer survivors thrust into a netherworld of chronic disability, afflicted with symptoms that include numbing fatigue, joint pain, mouth ulcers, mobility problems and severe cognitive impairment dubbed “chemobrain.” Their distress is compounded by doctors who dismiss their complaints as psychosomatic, and once-supportive family and friends who urge them to get on with their lives. The fact more women survive breast cancer permitted this pioneering study, says Subramanian. Yet they had difficulty finding funding, which ultimately came from the respected Susan G. Komen Foundation. “We were told it wasn’t a real phenomenon,” she says, noting she wasn’t surprised: “It’s the history of women’s medicine that we are hypochondriacs and hysterics and malingerers. And that is such an inappropriate way of managing the health care of half of the population.” Eileen Rakovitch, a radiation oncologist and chair of the breast cancer program at Toronto’s Sunnybrook hospital, views After the Cure as an invaluable addition to breast cancer literature, and intends to give copies to colleagues. “Although it’s important to emphasize breast cancer survivorship because mortality is declining, I don’t think we want to make it too glamorous and to make survivorship mean everything is as good as, and in some cases, better than before diagnosis because that’s not true for many women,” she says. One of her patients, a foreign correspondent, had such severe cognitive dysfunction she was unable to return to work. Raising awareness is their goal, says Subramanian, who has produced a documentary, Beyond Breast Cancer: Stories of Survivors. She wants doctors to inform women undergoing toxic remedies that there can be serious long-term problems in a small number of cases. It’s a difficult balance, Rakovitch notes: “At the time of diagnosis, women are so overwhelmed. They’re interested in surviving those two to three years rather than worrying about their cognitive status in three years.” She too would like physicians to inquire more actively about post- treatment symptoms and validate women who come to them with complaints. Medical acknowledgment is crucial, says Abel: “Without validation, employers won’t listen, family members think they’re malingering, and people can’t get disability benefits.” Many women interviewed in After the Cure bristle against the unrealistic cultural expectations placed on a buoyant recovery. One speaks of coming to terms with malingering lymphedema and chemobrain: “So I don’t see them as symptoms anymore; I see them as, ‘this is how my life is now. It sucks; it will always suck.’ But if I spend all of my time thinking how rotten it is, I’m not going to have any life.” Rakovitch believes post-treatment life is the next step in breast cancer research, noting studies are under way on the use of Ritalin to ease chemobrain. Karen Fergus, a Toronto-based psychologist who works with breast cancer patients, is co-authoring the first study of body image and sexuality among survivors. Abel and Subramanian are examining the use of acupuncture to alleviate fatigue. The lives of women living after The Cure can’t be tied up neatly with a pretty pink ribbon quite yet. ___________________________________________________________ November 22, 2008 Men's News DailyRobert A. Wascher, MD, FACS Breast Cancer & Fish Oil; Lymphedema after Breast Cancer Treatment; Vasectomy & Prostate Cancer Risk The information in this column is intended for informational purposes only, and does not constitute medical advice or recommendations by the author. Please consult with your physician before making any lifestyle or medication changes, or if you have any other concerns regarding your health. BREAST CANCER & FISH OIL It is well known that the omega fatty acids present in cold water fish can reduce the risk of heart disease. Now, new research, performed at the University of Texas in San Antonio suggests that fish oil may be able to inhibit the growth of breast cancer tumors as well. This research study, just published in the journal Breast Cancer Research & Treatment, used a mouse model of breast cancer to assess the effects of dietary fish oil supplements on breast cancer tumors implanted into laboratory mice, and on human breast cancer cells grown in laboratory cultures. Using sophisticated genetic tests, the researchers found that dietary fish oil inhibited genes associated with tumor growth while, simultaneously, increasing the activity of genes associated with tumor cell death. Regression of the implanted human breast tumors was also observed when mice were fed a diet containing omega fatty acids derived from fish oil. In order to further evaluate the effects of fish oil on breast cancer cells, the researchers added DHA and EPA, the two active omega fatty acids found in most fish oil supplements, to human breast cancer cells growing in culture dishes. Once again, the scientists found that fish oil significantly inhibited genes associated with tumor growth, and simulated other genes associated with tumor cell death. In particular, fish oil appeared to increase the activity of a gene called PTEN, which belongs to a class of genes called tumor suppressor genes. The PTEN gene plays a very important role in signaling normal cells to stop dividing when it is inappropriate for them to do so. PTEN, along with multiple other tumor suppressor genes, also helps to shunt damaged or abnormal cells into a cellular suicide pathway known as apoptosis. Together, these two protection mechanisms help to prevent uncontrolled cell growth that would, otherwise, result in the formation of tumors. In many cancers, the PTEN gene becomes inactivated by mutations, resulting in uncontrolled tumor growth, as well as tumor cell resistance to the apoptosis cell suicide pathway. Interestingly, an inherited mutation that inactivates the PTEN gene is known to cause Cowden’s Syndrome. People with Cowden’s Syndrome develop multiple benign tumors, or hamartomas, of the GI tract, bones, brain, eyes and urinary tract. At the same time, this hereditary cancer syndrome is associated with an increased risk of cancers of the breast, thyroid and uterus. This study’s finding that fish oil increases the activity of the PTEN gene is a potentially important discovery, as are the other apparent anti-tumor effects of fish oil on other important cancer-associated genes. However, my enthusiasm for the findings of this study is tempered by the fact that, so far, these anti-tumor effects of fish oil have only been observed in cell cultures and in immune-compromised mice that have been implanted with human breast cancer cells. As has been, unfortunately, shown in thousands of prior research studies using cultured cancer cells or laboratory animals, there is no guarantee that these same findings will be reproducible in humans. These exciting findings with a relatively non-toxic dietary supplement should, therefore, now be studied in human patients with breast cancer as a potential complementary therapy, and as a potential cancer prevention agent in women who are at significantly increased risk of developing breast cancer. LYMPHEDEMA AFTER BREAST CANCER TREATMENT Arm lymphedema, or chronic swelling of the arm, occurs in 10 to 30 percent of women following treatment for breast cancer. When the lymphatic drainage network in the arm has been disrupted by the surgical removal of armpit lymph nodes by the surgeon, or by radiation therapy to the armpit area (or, sometimes, following both types of treatment), the delicate network of lymphatic vessels that return excess tissue fluid back to the heart can become obstructed. This lymphatic obstruction can result in chronic swelling of the hand and arm. Patients with significant lymphedema of the arm, following breast cancer treatment, may experience considerable swelling (edema), heaviness, stiffness and discomfort of the affected hand and arm. A newly published study in the journal Breast Cancer Treatment & Research has taken a new look at factors associated with arm lymphedema following breast cancer treatment. This study was performed by researchers at the University of Southern California, the City of Hope in California, the National Cancer Institute in Bethesda, the Fred Hutchinson Cancer Center in Seattle, and the University of Louisville in Kentucky. In this study, nearly 500 women who had been diagnosed with preinvasive or invasive breast cancer completed an initial interview with study researchers. A follow-up interview was then performed, on average, about 4 years later. The researchers then analyzed the resulting data from these two sets of interviews. This study confirmed the findings of numerous prior studies that have linked the surgical removal of armpit lymph nodes, obesity, and high blood pressure with chronic arm lymphedema. In this study, women with high blood pressure were found to have almost two-and-a-half times the risk of developing lymphedema following breast cancer treatment when compared to women who did not have hypertension. Moreover, this hypertension-associated risk of lymphedema was essentially equivalent to the level of risk associated with the surgical removal of armpit lymph nodes and with obesity, which is a much higher level of risk than has been reported by most prior studies. Taken together, the results of this study confirm several previously established risk factors for arm lymphedema following breast cancer therapy, but also suggest that high blood pressure may, by itself, be a more significant risk factor for lymphedema than has been previously appreciated. The good news is that there are strategies available to most women that can address these lymphedema risk factors. Recently, a relatively new surgical technique has been developed, and allows surgeons to remove only one or a couple of lymph nodes (sentinel lymph node biopsy) in the 60 to 70 percent of breast cancer patients whose breast cancer has not yet spread to lymph nodes in the armpit area. Sentinel lymph node biopsy has been shown to reduce the risk of lymphedema to one-tenth the risk associated with the more radical complete axillary lymph node dissection that was formerly performed on all breast cancer patients. Likewise, losing excess weight may also reduce the incidence of obesity- associated lymphedema. The findings of this study also suggest that achieving good control of hypertension may reduce the volume of edema fluid generated in the arms of patients who have undergone breast cancer therapy, and may further reduce the risk of chronic lymphedema. For additional information on the subject of chronic lymphedema following breast cancer therapy and sentinel lymph node biopsy for breast cancer, please see the following links: http://www.cancersupportivecare.com/Abstracts/asbdpbtps.html http://meeting.ascopubs.org/cgi/content/abstract/23/16_suppl/8185 http://www.annalssurgicaloncology.org/cgi/content/abstract/15/7/1996 http://www.cancerlynx.com/sln.html VASECTOMY & PROSTATE CANCER RISK Despite the fact that the majority of scientific evidence suggests no association between vasectomy and the risk of prostate cancer, several previously published studies have raised concerns that men with a family history of prostate cancer, and men who undergo vasectomy at a young age, may be at an increased lifetime risk of developing prostate cancer following vasectomy. A newly published study in the Journal of Urology adds further weight to prior studies showing that vasectomy is not associated with an increased risk of developing prostate cancer. This clinical study was performed by scientists at the Fred Hutchinson Cancer Center and the University of Washington. More than 1,000 men recently diagnosed with prostate cancer were compared to 942 men without prostate cancer. All of these study volunteers were matched with each other in terms of age, race, and other important factors known to be related to prostate cancer risk. Following detailed interviews with all of the men participating in this study, the researchers found absolutely no difference in the number of men in either group who had previously undergone vasectomy. In both groups of men, 36 percent had previously undergone vasectomy for the purpose of sterilization. Furthermore, the men who had undergone vasectomy at a young age did not appear to experience any increased subsequent risk of developing prostate cancer when compared to the men who had undergone vasectomy later in life, and when compared to the men who had never undergone vasectomy. The findings of this clinical study should be reassuring to men who are considering sterilization by vasectomy (at least with respect to their lifetime risk of developing prostate cancer). ——————————————————————————– Disclaimer: As always, my advice to readers is to seek the advice of your physician before making any significant changes in medications, diet, or level of physical activity. ——————————————————————————– Dr. Wascher is an oncologic surgeon, professor of surgery, a widely published author, and the Director of the Division of Surgical Oncology at Newark Beth Israel Medical Center: http://www.sbhcs.com/hospitals/newark_beth_israel/mservices/oncology/surgical.html Send your feedback to Dr. Wascher at rwascher@doctorwascher.net __________________________________________________________ November 23, 2008 Enterprise-Record Daily Planner THERAPEUTIC DANCE: 6-7 p.m. Healing through movement and dance; exercise program helps regain range of motion, increase flexibility, reduce swelling from Lymphedema, promote positive self- image. Any age, fitness level. $10 fee first class. Enloe Cancer Center Conference Room, 251 Cohasset Road. Register, 332-3855. __________________________________________________________ November 24, 2008 Carlsbad Current Argus Business Briefs Homecare Connection & Hospice celebrates National Homecare & Hospice Month by announcing massage therapists available for all our clients and coming soon Tammy Clifton, Carlsbad's only licensed lymphedema therapist. Call 887-6050 for more information. __________________________________________________________________________ November 24, 2008 CBCNews.com Some breast cancers may clear up without treatment: study A significant portion of invasive breast cancers may regress on their own without treatment, a new study that is bound to provoke controversy suggests. The study, published Monday in the journal Archives of Internal Medicine, suggests breast cancer screening may be leading to over diagnosis of cancer, with upwards of 22 per cent of cases likely to resolve themselves without treatment. Once a breast cancer is found, it wouldn't currently be considered ethical not to treat. So — if the theory is correct — large numbers of women may be having surgeries, radiation, chemotherapy and other treatments that would never have been needed if their cancers hadn't been detected. "If we are right, then this is a kind of paradigm shift," said lead author Dr. Per-Henrik Zahl, a senior statistician with the Norwegian Institute of Public Health. Zahl, who admitted he has been trying to get the study published for about four years, said the risks of over diagnosis of breast cancer are real. Radiation can do significant and permanent damage to the heart and coronary arteries. Chemotherapy can cause cognitive confusion. And surgery that involves the removal of lymph nodes can cause lymphedema, the painful swelling of the arm closest to the involved breast. Dr. Patrick Remington has been studying the idea of self-limiting breast cancers since the early 1990s, when the introduction of breast screening programs showed a sharp and sustained increase in the incidence of the disease in the United States. He is convinced some invasive breast cancers do regress; they have become known as LMPs or cancers of "limited malignant potential." "I would say a very good guess would be about one out of three women have cancers detected today that would not have progressed otherwise," said Remington, a professor of population health sciences at the University of Wisconsin. Remington was not involved in this study. He notes some other types of cancers — prostate and recently lung — have been shown to spontaneously regress in some patients. In the case of prostate cancer, some physicians urge an approach known as watchful waiting, where patients are monitored to see if their disease is progressing; only then is it treated. That approach is not currently an option with breast cancer. Several journals refused to publish study Zahl's findings are likely to spark heated debate. In fact, he acknowledged several journals refused to publish the study before it was accepted by Archives of Internal Medicine, a journal published by the American Medical Association. "It is important to realize that this study did not study breast cancer regression but raised this as a possible explanation for their findings," cautioned Dr. Daniel Rayson, a medical oncologist at the QEII Cancer Care Program in Halifax. "Much more needs to be learned before drawing any definite conclusions and, in the meantime, no documented abnormalities on mammograms should be ignored," he added in an e-mail. An editorial in the journal stressed that the findings are consistent with several observations about breast cancer that have troubled investigators for years.And the editorial's authors, Dr. Robert Kaplan of the UCLA School of Public Health and Dr. Franz Porzsolt of Germany's Clinical Economics University of Ulm, said the hypothesis of breast cancer regression, while counterintuitive, is "difficult to rule out." "We know from autopsy studies that a significant number of women die [from other causes] without knowing that they had breast cancer," they noted. Dr. Steven Narod, a leading breast cancer researcher at Toronto's Sunnybrook Health Sciences Centre, agreed the findings are persuasive. Some breast cancers disappear on their own "I do agree with them that the best explanation of the findings is that about 10 to 20 per cent of the breast cancers … disappeared on their own," he said. "I'm still a bit skeptical and there's alternative explanations, but I think this one is worth paying attention to." In what Narod described as an "elegant" study design, Zahl and his colleagues used the introduction of a breast cancer screening program in Norway to explore the question. They compared breast cancer rates among nearly 120,000 women who had three rounds of mammography between 1996 and 2001 to those among nearly 110,000 women of the same age range (50 to 64) in the five-year period preceding the start of the breast cancer screening program. Those women, known as the controls, had one mammogram. In statistical terms, the two groups of women were identical. Their educational profile was closely matched, they had roughly the same average family income and the same average number of children. So the rates of cancers in the two groups should have been equal. In fact, the women who hadn't been regularly screened had 22 per cent fewer breast cancers. The authors explore a number of arguments about why that might be. They noted for instance that use of hormone replacement therapy in the part of Norway where the women lived increased substantially between 1996 and 2001, the period when the screened women were undergoing regular mammograms. HRT use is linked to increased risk of breast cancer. Looking for an explanation But the authors conclude none of the potential other explanations could account for such a large difference between the two groups. "All the caveats that could be explored have been explored in terms of accounting for the things that people would call ... weaknesses" of the study, agreed Dr. Cornelia Baines, a professor in the University of Toronto's school of public health and co-principal investigator of a landmark study into mammography, the Canadian National Breast Screening Study. Baines, who has been diagnosed with breast cancer that was earlier missed in a mammogram, said the findings are important. But she added that even if Zahl and his co-authors are correct, there's no way currently to put the findings into application. "The incontrovertible truth is that once you've screened a woman and you find an abnormality, you have to biopsy," she said. "If you biopsy, you have to follow through with surgery if the biopsy reveals malignant tissue. You can't stop that. You can't say: 'Well, I've been screened and there is a chance that this is over diagnosis.' You can't do that." No scientific reason for why cancers regress Finding ways to answer the questions raised by the study will be difficult, experts said. Remington noted even if doctors could differentiate, women and-or their health-care professionals might still opt for treatment to play it safe. He suggested, though, studying women whose cancers regress on their own could teach scientists how to trigger the same response in women whose cancers aren't self-limiting, and maybe even to prevent breast cancer from developing. In the meantime, Baines said, this study may serve as an important reminder to women and the medical community. "What is important and it seems to me it's been ignored for a long, long time is that …screening doesn't only have upsides. It has downsides," she said. "And if women want to accept the downsides and proceed with screening, then that's great. But I personally believe that they should only make that choice when they are fully informed. And a lot of them have not been fully informed about the over diagnosis scenario." __________________________________________________________________________ November 24, 2008 Daily Breeze Lymphedema support group explores latest treatment techniques. Torrance Memorial Medical Center, Health Conference Center Conference Room, 3330 Lomita Blvd., Torrance, noon to 1:30 p.m. the last Tuesday of the month. Call Paula Bauer at 310-517-4665 or Anne Clary at 310-376-3550. __________________________________________________________________________ November 26, 2008 Researchers Target Lymphatic System Cause Behind Many Diseases PowerHomeBiz.com The lymphatic system is the body's first line of defense against disease. As the body's internal cleansing waterway, it plays an indispensable role in immunity and in the body's immune surveillance against cancer. November 26, 2008 ( PowerHomeBiz ) - Nevada -- Dr. Paul Yanick was born with a systemic lymphatic disease that caused him to go deaf and lose kidney function in his late teens. During his childhood, his parents sought out every renowned specialist and were distraught and overwhelmed to find extremely limited information and treatments available for lymphatic disorders. Today, forty years later, despite being sent home to die at only twenty years old; Yanick tells his story and highlights his research in this neglected medical field in a new e-book entitled "The Forgotten River of Health." He reviews his hundreds of research studies which started in 1976 in the Journal of the American Audiology Society with a clinical study that linked the swelling of lymph fluids to deafness and brain and nervous system abnormalities. Yanick is not alone citing the medical neglect of the lymphatic system. The 2006 Senate Appropriations Committee Report stated "The lymphatic system is central to the progression of disease and the maintenance of health, yet scientific and medical knowledge of this important system is woefully deficient. According to Michael Detmar, PhD this forgotten river of health provides a "… hot new field. We are in a pioneering phase; there is still so much to discover." Just as the currents of a river run through the mountains and valleys to cleanse out the landscape, the body's internal waterways made up of lymphatic fluids function as a "river of health," cleansing the body by carrying away accumulated wastes and foreign invaders. This powerful cleansing aqueduct is actually twice as large as there are twice as many lymph vessels as there are blood vessels. The lymphatic system is the body's first line of defense against disease. As the body's internal cleansing waterway, it plays an indispensible role in immunity and in the body's immune surveillance against cancer. When immune surveillance fails, cancer grows and spreads (metastasizes), and inflammatory diseases like fibromyalgia, lupus, arthritis, and shingles progress into incapacitating disorders. The lymphatic system is the most forgotten and neglected system of the entire body. It is composed of a network of thin tubes that branch, like blood vessels. These lymphatic capillaries carry lymph fluid into tissues throughout the body. Lymph fluid is loaded with infection-fighting cells called lymphocytes that originate from clusters of bean-shaped organs called lymph nodes, which are found under the arms and in the groin, neck, chest, and abdomen. Lymphatic organs include the spleen, thymus, tonsils, and bone marrow. Designed to function as a cleansing aqueduct, bathing each cell and draining away detritus through the circulatory system, its malfunction causes brain fog, chemical sensitivity, depression, fatigue, headaches and often a feeling of heaviness in the abdomen. Stagnant lymph interferes with the body's ability to cleanse viruses, bacteria, mutagenic cells, metabolic toxins and cancer, and it inhibits critical self-repair and self-healing mechanisms in the body, causing acne, skin rashes, cysts, tumors, fibrocystic breast lumps, fatty tumors, and in advanced cases spider veins and cellulite. In 2005 Nature (436:28) an article entitled "Unlocking the Drains" stated, "After centuries of playing second fiddle to the blood system, our lymphatic circulation is coming into its own as a key player in diseases ranging from cancer to asthma. Once dismissed as a mere drainage network, the body's 'second circulation' [lymphatic system] is emerging as a crucial player in numerous diseases….and as a vital part of the normal immune system." Dr. Robert Smith, director of cancer screening for the American Cancer Society stated, "Lymphatic diseases, including lymphedema are important health problems which until very recently received far too little attention." Wendy Chaite, the Founder and President of the Lymphatic Research Foundation (LRF), states, "It is the lymphatic system, after all, that is the body's first defense against disease. A disorder of the lymphatic system affects virtually every other system in the body. Research into how the lymphatic system works promises preventive and therapeutic benefits for millions of people afflicted with a broad array of diseases. There is tremendous potential for health benefits hidden within the lymphatic system. The power to discover these benefits is in the hands of the researchers and in the will of the patient community and their loved ones." Does your lymphatic system need attention? If you are overweight around the abdomen, have skin abnormalities, allergies, digestive disorders or have chronic fatigue , anxiety or nervous system issues, your lymphatic system is already moderately compromised. If you've been diagnosed with fibromyalgia, cancer, multiple sclerosis , multiple chemical sensitivity, Parkinson's or Alzheimer's disease , lupus, arthritis, asthma or have cellulite or varicose veins your lymphatic system is chronically compromised with no traditional medical cure available. Contact Details: Dr. Paul Yanick URL: http://www.quantafood.com/ ___________________________________________________________________________ November 30, 2008 TampaBay.comBy Christina K. Cosdon Nursing society, store team to help breast cancer survivors The day before she was planning to participate in a Susan G. Koman race for breast cancer, Joyce Kubala discovered a lump in her right breast. Following a lumpectomy, radiation and chemotherapy treatments, the 49-year-old married mother of three was cancer free for nearly four years. But the summer of 2007, the cancer returned in the same breast and she underwent a double mastectomy. Annie Roberson, a 74-year-old grandmother and widow, learned she had cancer in her left breast the spring of '07, following a yearly mammogram. After a mastectomy, she underwent chemotherapy. Since the surgery, she has suffered from lymphedema, a swelling in the arm when lymph nodes or vessels are removed or severed, and has to have treatments and wear a special compression sleeve. Kubala and Roberson, both St. Petersburg residents, wore over-the-counter breast forms after surgery. Neither woman's insurance would pay for custom breast prostheses. Enter Wendy Migliore, a nurse oncologist with the Pinellas County Oncology Nursing Society and board member of the Gulf Coast Oncology Foundation. The Society received a grant this year to give custom breast prostheses to cancer survivors who couldn't afford them. "We received money to give prostheses to three women," said Migliore. Kubala was recommended by one of her doctors and Roberson was recommended by a foundation board member who met her through a support group. Because Kubala had a double mastectomy, it was decided to give her two of the three prostheses covered by the grant. Both women were fitted for their new prostheses at Karen de Vlaming's business, Beautiful Transitions in Largo. The business specializes in over-the-counter and custom prostheses, clothing, wigs and skin care for cancer patients and survivors. Both women said they are delighted with their new prostheses. The prostheses "feel good and are very comfortable," said Kubala. "I can even glue them on and wear them without a bra." "I feel so much better," she said, "and that has given me a lot of self-esteem." "This is great," said Roberson. "It makes it feel like I have my original breast and it matches my skin." Chris Cosdon can be reached at ccosdon@gmail.com. ___________________________________________________________________________ November 30, 2008 Enterprise-Record Daily Planner THERAPEUTIC DANCE: 6-7 p.m. Healing through movement and dance; exercise program helps regain range of motion, increase flexibility, reduce swelling from Lymphedema, promote positive self-image. Any age, fitness level. $10 fee first class. Enloe Cancer Center Conference Room, 251 Cohasset Road. Register, 332-3855. __________________________________________________________________________ November 30, 2008 LivestrongLance Armstrong Foundation Lymphedema Lymphedema: Detailed Information This information is meant to be a general introduction to this topic. The purpose is to provide a starting point for you to become more informed about important matters that may be affecting your life as a survivor and to provide ideas about steps you can take to learn more. This information is not intended nor should it be interpreted as providing professional medical, legal and financial advice. You should consult a trained professional for more information. Please read the Suggestions and Additional Resources documents for questions to ask and for more resources. What is lymphedema?Some cancer survivors may experience lymphedema as a side effect of surgeries or the type of treatment they needed for their cancer. Lymphedema is a condition that affects your lymphatic system, which is made up of tissues and organs in your body. These tissues and organs produce, store and carry the white blood cells that help fight infections and other diseases.Lymphedema - officially called “secondary lymphedema” – is swelling of arms, legs or trunk that occurs from the build-up of lymph fluid. Lymph fluid is the clear fluid that travels through the lymphatic system and carries cells that help fight infections and other diseases. Lymphedema stops lymph fluid from flowing freely in your body and often causes swelling in your body that you can see and feel.Lymphedema is a very treatable condition. If you experience lymphedema it isn’ t because your health care team didn’t do a good job of treating your cancer. Sometimes radiation damages lymph nodes and lymphedema can’t be avoided. Surgeries that remove your lymph nodes are also sometimes a necessary part of treating your cancer. This is unfortunate, but your health care team’s primary goal was to treat your cancer. Now, they can work with you to prevent or manage any aftereffects you might experience.While it may seem frustrating at times to have to worry about health conditions after you have survived something like cancer, it’s important to be aware of your risks of aftereffects like lymphedema and watch for symptoms to increase your chances of early detection.Who might be at risk for lymphedema?People who have had the following procedures are at risk for developing lymphedema: Biopsy Lumpectomy Simple mastectomy Modified radical mastectomy with node dissection in the armpit Surgery or biopsies that sample lymph nodes or disrupt lymph flow in the groin or axilla (armpit); these may include surgeries for prostate and gynecological cancers and melanoma Sentinel lymph node mapping procedures (use of dyes and radioactive substances to identify lymph nodes that contain tumor cells) Survivors of the following cancer types are at risk for developing lymphedema: Breast cancer Melanoma Prostate cancer Ovarian cancer Head and neck cancers Cancers involving lymph node dissection and radiation to the lymph nodes Other factors such as being seriously overweight, having diabetes and taking certain medications such as steroids may put a survivor at risk for lymphedema. However there hasn’t been a lot of research done about whether or not these factors increase your risk for lymphedema. You might want to discuss these factors with your health care team if any apply to you.What are some symptoms of lymphedema?Some of the symptoms of lymphedema are: Noticeable swelling of the arms, legs or trunk Feeling of fullness or discomfort in an arm or leg Not being as flexible in the hand, wrist or ankle Sudden and extreme difficulty fitting into your clothes Sudden and extreme tightness of rings, watch or bracelet Infections that won’t go away or keep coming back in the same area Feeling of tightness in the skin (which may be felt even before there is noticeable swelling) Symptoms and swelling may appear for a short time, disappear without treatment and then may return permanently. When you notice any symptoms, write down when they happened, what you were doing and what, if anything, made it better. Sometimes when the swelling comes and goes often, it might be the beginning of lymphedema. Early detection and treatment are very important. Once swelling becomes constant, it is not reversible, but only manageable. You may be the first to notice your symptoms of lymphedema, so look over your body regularly for changes.Why does cancer or its treatment sometimes cause lymphedema?Even though other non-cancer conditions can cause lymphedema, it often happens after a treatment that changes your lymph nodes. Remember, lymphedema does not happen because your treatment wasn’t done correctly. However, you might want to understand why certain treatments sometimes cause lymphedema.Cancer-related procedures that increase the chances of developing lymphedema include: Biopsy: A biopsy is when tissue around your tumor is removed for testing. This may damage lymphatic pathways and may allow bacteria to enter the body through the break in the skin. Damage to the lymph pathway and infection both cause increased congestion, a first step in the development of lymphedema. Surgery: You may have lymph nodes removed during surgeries for melanoma or breast, gynecological, head and neck, prostate, testicular, bladder or colon cancer. This puts survivors at risk of developing lymphedema. Lymph node mapping: Lymph node mapping involves the injection of a dye to trace the flow of lymphatic fluid from the tumor to the nearest lymph nodes. This may cause damage to the lymphatic system. Radiation therapy: Radiation kills cancer cells that might be left behind after surgery. Radiation therapy often causes fibrosis or thickening of the tissues in the area of your body that received radiation. The thickening of the tissue may make it harder for lymph fluid to flow from your legs and arms into the middle of your body. When could lymphedema happen?Lymphedema can occur during treatment or years after your treatment ends. Because there isn’t an exact time period where you might be at risk, it’s important to go for check- ups and look for changes in your body that might be symptoms of lymphedema. Whether or not you will get lymphedema or when really depends on the type of cancer you had, the type of treatment you received and how your body handled it all.Is there a cure for lymphedema?There is no cure for lymphedema, but you can manage it with quick and effective treatment. Getting it diagnosed early and treating any temporary swelling you might experience can prevent chronic (permanent) lymphedema from happening.The lymphatic system can function at a higher level when your body needs it to do so, but only for a brief period of time. Once the lymphatic system fails to keep up with how much fluid your body needs it to pump, it may not do a good enough job of moving the fluid where it needs to go in your body. An infection can cause damage to the lymphatic system. It is very important to protect the lymph vessels in order for the lymphatics to work as well as they can.What can be done to minimize a survivor’s risks for developing lymphedema?Below is a brief list. For more information, see Suggestions. Discuss treatment alternatives that may reduce your risk for lymphedema with your health care team Talk to other survivors about ways they manage their lymphedema Learn about strategies to minimize your risk for lymphedema Learn about lymphedema therapy This document was produced in collaboration with: Jane M. Armer, RN, PhD Associate Professor, Sinclair School of Nursing Director, Nursing Research, Ellis Fischel Cancer Center University of Missouri-Columbia Works CitedInternational Society of Lymphology. "The diagnosis and treatment of peripheral lymphedema: Consensus document of the International Society of Lymphology." Lymphology 36 (2003): 84-91."18 Steps to Prevention for Upper Extremities." Lymphnet.org. National Lymphedema Network. January 2001 Ridner SH. "Breast cancer lymphedema: pathophysiology and risk reduction guidelines." Oncology Nursing Forum 29(9) (Oct. 2002): 1285-93.[return to top] Lymphedema: Suggestions The suggestions that follow are based on the information presented in the Detailed Information document. They are meant to help you take what you learn and apply the information to your own needs. This information is not intended nor should it be interpreted as providing professional medical, legal and financial advice. You should consult a trained professional for more information. Please read the Additional Resources document for links to more resources.Discuss treatment alternatives that may reduce your risk for lymphedema with your health care team: Before any major procedure - a biopsy, lymph node mapping or an operation - talk with your health care team about your potential risks for lymphedema and ways to reduce these risks. With proper education and care, you can decrease your chances of developing lymphedema.Talk to other survivors about ways they manage their lymphedema:Support groups provide a safe environment to share experiences with other survivors, learn new ways to handle difficult situations and talk about the emotions. You will see different styles of coping with stress and adjusting to life as a cancer survivor. If you are uncomfortable talking about certain subjects with your family or friends, a support group offers you a place to talk freely about what is important to you.Ways to find out more about support groups in your area: Ask your health care team for suggestions. Some cancer programs offer support groups for cancer survivors and their family members right in the clinic or hospital. Call a nearby cancer center or university hospital and ask about support groups. Call the American Cancer Society at 1-800-ACS-2345 (1-800-227-2345) and request a list of support groups and cancer centers in your area. Visit LIVESTRONGTM SurvivorCare at www.livestrong.org/survivorcare, or call 1-866-235-7205 for information on support groups. Learn about strategies to minimize your risk for lymphedema:Review these suggestions carefully with a member of your health care team.Strategies Management Watch for even slight increase in size or swelling of the arm, hand, fingers, chest wall, trunk or legs. Contact your health care team as soon as you notice any one of these symptoms. Avoid having injections, finger sticks, or blood draws from the arm that might be at risk for lymphedema. If there is no other option, the injection or stick site needs to be carefully prepared with an antiseptic and covered with a protective bandage afterwards. You should tell the person injecting your arm that you might be at risk for lymphedema. Do not have blood pressure checked from the at-risk arm. After procedures involving the breast or the armpit, use the arm on the unaffected side for blood pressure checks. When procedures have involved both sides of the body, use the thigh for blood pressures checks. You should tell the person taking your blood pressure that you might be at risk for lymphedema. Keep the skin of at-risk arms or legs very clean and healthy. Use moisturizing cream or lotion (such as Eucerin, Lymphoderm, Curel) after bathing. Dry gently but thoroughly. Make sure the at-risk arm or leg gets proper circulation. You can do this by occasionally raising the at- risk or affected arm or leg above the level of your heart. Avoid vigorous, repetitive movements against resistance with the at-risk arm or leg. Use the other limb if possible or ask for help. You should also avoid scrubbing, pushing, pulling, etc. Avoid heavy lifting or putting excessive pressure on the affected limb. Limit lifting to less than 15 lbs Women using breast prostheses after mastectomy should select a lightweight prosthetic Use only loose-fitting jewelry around at-risk or affected fingers or arm(s). Never carry heavy handbags or bags with at-risk or affected arm. Do not use over-the-shoulder straps on the at-risk or affected side. Avoid extreme temperature changes on the at-risk arm or leg. Closely monitor temperature changes when bathing or washing dishes. Avoid saunas and hot tubs, or at least keep affected limbs out of extreme temperatures. Protect affected limbs from the sun at all times. Wear protective clothing and sunscreen. Minimize chances of any injury: bruising, cuts, sunburn or other burns, sports injuries, insect bites, animal bites or scratches to the affected arm or leg. Shave with an electric razor rather than a safety razor. Wear gloves while doing housework, gardening, or any type of work that could result in even a minor injury. Wear shoes or house slippers to protect feet. If you are getting your nails done, tell the manicurist or pedicurist of special needs and precautions. If injuries do occur, watch for signs of infection including swelling, redness, pain, and fever. Establish a safe exercise program. Consult with a member of your health care team before starting an exercise program. Try not to use an at-risk arm or leg too much. If there is discomfort, aching or pain, lie down and elevate the limb. Walking, swimming, light aerobics, bike riding, and specially designed ballet or yoga may be included in your safe exercise programs. Take special precautions when traveling by air. Wear a well-fitted compression sleeve or stocking. Additional bandages may be required on long flights. Increase fluid intake while in the air. Ask for guidance from a lymphedema specialist before travel. Learn about lymphedema therapy:Lymphedema therapy is provided by a therapist (physical therapist, occupational therapist, registered nurse, or massage therapist) who has specialized training in lymphedema management.Part of Standard Lymphedema Treatment What the Treatment Involves Compression Bandaging A well-fitted daytime compression garment prevents daytime swelling. An overnight garment reduces night-time swelling. Specialized bandaging is used around the clock during intensive treatment to reduce limb volume. Overnight bandaging may be continued as part of self-management to control swelling. Exercise Exercise under the guidance of the therapist and while the limb is under compression is carried out daily to help reduce limb swelling. Over-exertion is avoided to prevent fatigue and further swelling. Skin Care The skin is moisturized and protected from breakdown to prevent infection, which further increases limb swelling and can lead to life-threatening systemic infection. Healthy Diet Maintain a healthy weight with a well-balanced diet. Drink enough fluids. No dietary protein restriction is recommended, even though lymph is a protein-rich fluid. [return to top] Lymphedema: Additional Resources The resources listed below provide more detailed information and support services to help you with lymphedema. Please read the Detailed Information and Suggestions document for more information and questions to ask.Click a resource for more information: National Lymphedema Network (NLN) OncoLink LIVESTRONG SurvivorCare Program National Cancer Institute (NCI) American Cancer Society National Lymphedema Network (NLN) www.lymphnet.orgEmail: nln@lymphnet.org Phone: To listen to recorded information, call 1-800-541-3259. To speak to a representative, call 510-208-3200, Monday-Friday, 9:00 a.m. to 5:00 p.m. (PST). The National Lymphedema Network provides an overview of lymphedema that explains the symptoms, stages and treatments. The Web site includes tips on prevention, educational materials, a parenting network, and contact information for support groups. NLN also sponsors a "Netpals & Penpals" program that allows you to write to others with lymphedema. Lists of treatment centers, doctors, massage therapists and physical therapists are also included. Return to topOncoLink www.oncolink.orgEmail: Send email through the Web site. OncoLink is a multimedia cancer resource provided by the Abramson Cancer Center of the University of Pennsylvania. Patients and physicians can get information about all types of cancer, news about research advances, and updates on cancer treatment. The Web site includes a clinical trial matching service, answers to frequently asked questions, or you can email experts with your own personal questions. OncoLink is also available in Spanish. Return to topLIVESTRONG SurvivorCare Program www.livestrong.org/survivorcareEmail: Send email through the Web site. Phone: 1-866-235-7205 Case managers take calls Monday through Friday, 9:00 a.m. to 5:00 p.m. (EST). Voicemail is available after hours. LIVESTRONG SurvivorCare offers assistance to all cancer survivors, including the person diagnosed, caregivers, family and friends. The program provides education, information about treatment options and new treatments in development, counseling services and assistance with financial, employment or insurance issues. To provide these services, LIVESTRONG SurvivorCare has partnered with several organizations, including CancerCare, Patient Advocate Foundation and EmergingMed.The LIVESTRONG Survivorship Notebook is a tool that can help you organize and guide your cancer experience. The portable, three-ring binder contains a variety of information covering a full range of physical, emotional and practical survivorship topics. You may order a free LIVESTRONG Survivorship Notebook at www.livestrong.org/notebook. Shipping and handling charges will apply. Return to topNational Cancer Institute (NCI) www.cancer.govEmail: Send an email through the "Need Help?" section of Cancer.gov. Phone: 1-800-4-CANCER (1-800-422-6237) TTY for deaf and hard of hearing callers: 1-800-332-8615 English-speaking and Spanish-speaking information specialists answer calls Monday-Friday, 9:00 a.m. to 4:30 p.m. local time. Online: Immediate online assistance is available (in English only) through LiveHelp, an instant messaging system for typing in questions and receiving responses from information specialists. You can access LiveHelp from the "Need Help?" section of the Cancer.gov homepage Monday-Friday, 9:00 a.m. to 11: 00 p.m. (EST). Cancer.gov, the National Cancer Institute Web site, provides accurate, up-to-date information on many types of cancer and the challenges cancer can bring. You can also use the site to search for information by cancer type or topic, and you can access information about treatment-related issues. Information about financial and insurance matters is also included. You can learn how clinical trials work and search for a clinical trial in your area. This site has a detailed dictionary of cancer terms. Web site information and publications are available in Spanish. Return to topAmerican Cancer Society www.cancer.orgEmail: Questions can be submitted in English or Spanish from the "Contact Us" page. Phone: 1-800-ACS-2345 (1-800-227-2345) TTY for deaf or hard of hearing callers: 1-866-228-4327 English-speaking information specialists are available 24 hours a day. Spanish-speaking information specialists are available Monday-Friday, 6:30 a.m. to 7:00 p.m. (CST). You can leave a message in English or Spanish 24 hours a day. The American Cancer Society Web site contains information about many of the challenges of cancer and survivorship. You can search for information by cancer type or by topic. ACS provides a list of support groups in your area, or you can join online groups and message boards. Some information on the Web site is available in Spanish, Chinese, Korean and Vietnamese. Information specialists can answer questions 24 hours a day by phone or email. -------------------------------------------------------------- Holiday drive helps families through hard times By Katherine McInerney Thu Dec 04, 2008, 01:01 PM EST Norton - There’s a 12-year-old in Norton whose biggest wish this Christmas is that his mom, who suffers from stage three lymphedema, will get better. But it’s not likely that his wish will come true. There’s no cure for the disease, which debilitates Mary (names have been changed for this article) and other sufferers as bodily fluids accumulate in their limbs. The result is swollen, painful arms and legs, open sores that ooze fluid and threaten infection, and potential heart complications as the disease progresses to its fourth and final stage. Lymphedema has impaired Mary’s mobility and the quality of life she and her three boys previously enjoyed. “I’m just so sick of it,” said Mary, a single mom, who has made an estimated 20 trips to the hospital in the last year. Surprised to hear her 12-year-old son, Sam, reveal his Christmas wish, she added with tear-filled eyes, “That’s not what I want his biggest wish in life to be.” “My life is hectic” said Sam, who has had to take on a lot more responsibility since his mom got sick. He and his two brothers, ages 14 and 5, bounce from house to house when their mom is in the hospital. “Sometimes I don’t feel like doing it and sometimes I do,” Sam said. Lymphedema is caused by a compromised lymphatic system that doesn’t process fluids like it should. “My legs are like traffic jams,” Mary said, lifting up her pant leg to expose a bloated and red lower leg. Fluid trickled out of an open sore on her shin — she’d have to wash and wrap her legs later to avoid infection, Mary said. In January, Mary got MRSA, a staph infection, which if not treated properly could have been fatal. It took four and a half months for the infection to clear, during which time she had to stop physical therapy at a local lymphedema clinic because MRSA is so contagious. Mary also has several disrupted discs in her back — the result of two bad falls that she took while working on a demolition crew about three years ago. She lives a life of constant pain, which makes working impossible for this self-described workaholic. It also makes chasing after three boys a challenge. But she credits her kids, especially her oldest, Keith, 14, for taking responsibility and helping however they can. Whatever the family needs, Keith says “I’ll take care of it,” Mary said. But she wishes he didn’ t have to. People constantly tell Keith that he’s the man of the house, which frustrates his mother. “No he’s not,” Mary said. “He’s 14. He’s a kid.” As she struggles to feed and clothe her kids on a fixed income, this Christmas Mary has turned to the Norton Fire Department’s Christmas is for Kids drive in hopes that the community will help her give her kids a happy holiday. She listed her boys’ “biggest wish” — handheld video games that they can take with them in the car and to hospital waiting rooms, Mary said. The older boys would like PSPs (Personal PlayStations) and her youngest would like a Game Boy Advance. This will be the second year that Mary’s family has received donated gifts from Christmas is for Kids. “I can’t believe the generosity of some of the people and the way that they take care of the kids,” Mary said. “I know everybody’s story is different — everybody’s situation is different. But there are so many families that wouldn’t be able to make it without Christmas is for Kids.” The Norton Mirror Gifts of Hope campaign is supporting the Christmas is for Kids drive again this year. Each week throughout the holiday season the Mirror will publish an list of donors, along with a story on the program. Donations, payable to “Christmas is for Kids” can be sent to the Norton Mirror, 370 Paramount Drive, Unit 3, Raynham, MA 02767. Donors can also drop off unwrapped gifts at the Fire Headquarters at 70 East Main St or at the following businesses in Norton: Walgreen’s, Mansfield Bank, Epoch Assisted Living Center, and the North Easton Savings Bank on West Main Street. Anyone wishing to adopt a child or make a donation of gifts or money can contact Judy McCarron at 508-285-0248 or mccarronj@nortonfire.com. The deadline to drop off gifts for a child that has been adopted is Dec. 19. To date, the Mirror has received $250 in donations for the Christmas is for Kids drive. This week’s donors are Janet M. Kilguss and J. Ronald and M. Beatrice Nelson. Below is an updated wish list for the 2008 Christmas is for Kids drive. The kids listed below are those that still need to be adopted. ID Number; sex; age; toy request; clothing request; clothing size; shoe size. 4-1; F; 8; Nintendo DS games; pants; 7; 13 ½. 4-2; F; 12; Battleship board game; sports wear; W-10; 8. 5-1; F; 7; jeans; 8. 6-2; M; 2; trucks; pajamas; 4T. 7-1; F; 19 months; Elmo Live; shirts; 4T; 7 ½. 10-1; M; 5 ½; Nintendo System; jeans; 7X; 2 ½. 10-2; M; 5 ½; Nintendo System; pants; 6; 1 ½. 10-3; M; 4 ½; Nintendo System; pants; 5T; 1. 11-1; M; 6; S. B. Ocean Adventure game; pants; 8; 1. 12-1; M; 14. 12-2; M; 13. 12-3; F; 11; coat; 12. 12-4; M; 8; coat; 8. 13-1; M; 6. 14-2; M; 8; Nintendo DS Light; pants; 12 husky. 14-3; F; 13; iPod Nano; J.B. Sweatshirt; large. 16-1; F; 8; baby dolls; warm outfits; 8; 6. 16-2; M; 2; Elmo, V-Smile or Leapfrog; jeans; 3T; 8. 16-3; M; 6; V-Smile games; pajamas; 6; 1 ½.18-1; M; 7; Benten Alien Force (for PS 2); snow pants; 14/16; 6 ½. 19-1; F; 6; wooden dollhouse and accessories; anything; 7; 12. 19-2; M; 3; Didj by Leapfrog; jeans; 4; 9. 19-3; M; 5; V-Smile Cyber Pocket; anything; 5; 12. 20-1; M; 6; V-Smile Cyber Pocket; jeans/pants; 6; 12. 20-2; F; 2; Too Cute Twins; dresses; 3+. 20-3; M; 3; Didj by Leapfrog; jeans/pants; 4+; 10. 25-1; F; 13; computer games, board games; jeans, shirts; 3 jr.; 8 ½. 26-1; M; 14; PSP and games; sweats; M-L; 11. 26-2; M; 12; PSP and games; sweats; XL; 9. 26-3; M; 5; Nintendo DS and games; coat; 10; 3. 27-1; M; 10; Nintendo DS and games, education games; jacket; 12; 4. 27-2; F; 17; Nintendo DS and games or camera; coat; M; 8. 29-1; F; 11; Nintendo DS; jeans, shirts; 12; 4 ½. 29-2; F; 13; CDs (T.I. and Lil Wayne); socks, undies; 6; 9 ½. 30-1; M; 4; learning toys; pants, shirts; 6; 8. 31-1; F; 8; scooter, DS games; any clothing; 12; 3. 32-1; F; 4; Learning toys; pants, shirts; 5. 33-1; F; 14; stereo, softball equipment; jeans, sneakers; 12; 8 ½. 33-2; F; 7; Crayola H.M. Fashion Studio; jeans, sneakers; 6; 12 inf. 33-3; M; 1; F.P. ride-on trucks; pajamas, socks, outfits; 18 mos.; 4 inf. Katherine McInerney can be reached at 508-967-3508 http://www.wickedlocal.com/norton/news/x1009155090/Holiday-drive-help-families-through-hard-times ------------------------------------------------------------------------- Found an amazing pair of ultrasound videos of the upper neck showing the emptying of lymph (chyle) from the thoracic duct into the venous angle in a normal case and in the case of a patient with a faulty valve, causing neck swelling due to lymph stasis in the thoracic duct. http://content.nejm.org/cgi/content/full/359/22/e28?query=TOC Click on the word "videos" on the right or click on the small photos on left. ------------------------------------------------------------------------- Yesterday the FDA issued a class 1 recall of two unapproved devices. 1. Vibrational Integrated Bio-photonic Energizer Device. 2. HLX8 Device. For further information you can contact FDA directly if you are using either device or have questions. |