Postoperative Lymphedema Research Articles

Hand surgery after axillary lymph node clearance for breast cancer: contra-indication to surgery?

Breast cancer patients who have had prior axillary lymph node clearance (ALNC) can present with ipsilateral hand conditions that could easily be treated with surgical intervention. These patients are often advised to avoid interventional procedures due to risks of complications such as lymphoedema, infection and cellulitis. Between April and June 2009, we conducted an online survey of hand surgeons, breast surgeons and breast-care nurses to obtain their views on hand surgery after ipsilateral axillary lymph node clearance. The majority of hand surgeons (58%) felt there was no contra-indication to surgery in a breast cancer patient with prior ipsilateral ALNC compared to just 30% of breast surgeons and 10% of breast-care nurses. The majority of breast surgeons and breast-care nurses (70% and 89%, respectively) felt that hand surgery was a relative contra-indication compared to just 41% of hand surgeons. Postoperative lymphoedema was the commonest cited reason for avoiding surgery. The majority of hand surgeons (79%) and nearly two-thirds of breast surgeons (57%) would use a tourniquet during surgery if it was normal practice. A review of the published literature does not support the notion that these patients experience increased complications; therefore, we recommend the advice given to breast cancer patients regarding ipsilateral surgery be re-evaluated.

A Prospective Study of Postoperative Lymphedema After Surgery for Cervical Cancer

Lymphedema is a severe postoperative complication in oncological surgery. Multifrequency bioelectrical impedance analysis (MFBIA) is a new method for early lymphedema detection. The objective was to establish the methodology of MFBIA for lower-limb lymphedema and to detect a lymphedema in patients undergoing cervical cancer surgery. From a population of 60 patients undergoing cervical cancer surgery, 39 underwent radical hysterectomy Wertheim III (RAD group), and 21 underwent conservative surgery (laparoscopic lymphadenectomy plus simple trachelectomy/simple hysterectomy--CONS group). A control group of 29 patients (CONTR group) was used to determine the SD of impedance at zero frequency (R0). Patients were examined before surgery and at 3 and 6 months after surgery by MFBIA and by measuring the circumference of the lower limbs. No differences were found between the CONS and RAD groups on age, height, weight, and histopathologic type of tumor. However, the number of dissected lymph nodes differed significantly between the groups (17.3 in the CONS group vs 25.8 in the RAD group, P = 0.0012). The SD of R0 in the CONTR group was 36.0 and 39.0 for the right and the left leg, respectively. No difference in prevalence of lymphedema based on circumference method was found (35.9% in the RAD and 47.6% in the CONS groups, not statistically significant). No difference in the prevalence of lymphedema was found between the CONS and RAD groups. A methodology for MFBIA for the detection of lower-limb lymphedema was described.

A prospective analysis of the incidence of postoperative lymphedema 1 to 2 years after surgery and axillary dissection in early breast cancer (BC) patients treated with concomitant irradiation and anthracyclines followed by paclitaxel.

e11059 Background: Lymphedema (LE), a debilitating complication after axillary dissection and irradiation, is caused by the accumulation of interstitial fluid of the affected arm due to a blockage ...

Obesity is a Risk Factor for Developing Postoperative Lymphedema in Breast Cancer Patients

Lymphedema (LE) is a well-known postoperative complication after axillary node dissection (ALND). Although, sentinel lymph node dissection (SLND) involves more focused surgery and less disruption of the axilla, early reports show up to 13% of patients experience some symptoms of LE. The purpose of this study was to determine predictors of arm LE in our patients under going SLND with or without an ALND. One hundred and thirty-seven breast cancer patients were treated at a comprehensive cancer center. Prospective measurement of arm volume was carried every 6 months from date of diagnosis. This data base was retrospectively reviewed for tumor stage, treatment, and subjective complaints of LE. Objective LE was defined as a change greater than 200 mL compared with the control arm. Univariate and multivariate analyses were performed. Arm volume changes were measured over 24 months (median follow-up 20 months) in 137 women: 82 stage I, 48 stage II, and 5 stage III; median age 56 years. Breast-conserving surgery was performed in 133 patients. All patients underwent SLND for axillary staging and for 52 patients this was the only axillary staging procedure. All node-positive patients (31) and 54 node-negative patients under went an immediate completion ALND, the latter as part of a study protocol. At 24 months, 16 (11.6%) patients were found to have objective LE (>200 mL increase). Patient age, tumor size, number of nodes harvested, or adjuvant chemotherapy was not found to be predictive of LE by univariate analysis. The risk of developing postoperative LE was primarily and significantly related to the patients' BMI (p = 0.003). Multivariate analysis revealed patients with a BMI >30 (obese) had an odds ratio of 2.93 (95% CI 1.03-8.31) compared with those with a BMI of <25 of having LE. Symptomatic LE (SLE), as defined by patient complaints was recorded in six of the above 16 patients, no SLE was recorded in patients without objective signs of edema. Univariate subgroup analysis compared the symptomatic to the nonsymptomatic patients and revealed the median number of nodes removed was higher in the symptomatic patients (17 verses 9, p = 0.045); however, these patients had a lower BMI (p = 0.0012). The mean change in arm volume was not significantly different between the groups. SLE occurs in one third of patients with objective arm swelling and most likely is multi-factorial in etiology. Although patients undergoing SLN were recorded as having objective LE, none reported SLE. The development of LE within 2 years of surgery is associated with the patient's BMI and this should be considered in preoperative counseling.

Scientific Impact Award: Axillary reverse mapping (ARM) to identify and protect lymphatics draining the arm during axillary lymphadenectomy

Introduction The axillary reverse mapping (ARM) procedure distinguishes lymphatics draining the arm from those draining the breast. The aim of this study was to assess the ability of ARM to identify and preserve lymphatics draining the arm and the impact on lymphedema. Methods This study included 220 patients undergoing sentinel lymph node (SLN) biopsy (SLNB) with or without axillary lymph node dissection (ALND) from May 2006 to September 2008. After SLN localization with a radioactive tracer, blue dye was used to map ARM lymphatics. Data were collected on identification and variations in lymphatic drainage, crossover rate, the incidence of metastases, and nodal status. Results Crossover (ARM = SLN) occurred in 6 patients (2.8%). ARM lymphatics were near or in the SLN field in 40.6% of patients, placing it at risk for disruption during lymphadenectomy. ARM lymphatics juxtaposed to the hot SLNB (n = 12 [5.6%]) were preserved. Fifteen ARM nodes were excised and were negative even in positive axillae. There were no cases of lymphedema at 6-month follow-up where ARM nodes were preserved. Conclusion Confluence of the arm and breast drainage is rarely the SLN, and none of these nodes contained metastases. Preserving the ARM nodes may translate into a lower incidence of postoperative lymphedema.

Sentinel node biopsy and quality of life measures in a Chinese population

Background Sentinel lymph node biopsy (SLNB) has become an alternative procedure of axillary lymph node dissection (ALND) with a lower risk of significant operative morbidity. The primary aim of the present study was to evaluate the morbidity and quality-of-life (QoL) after SLNB or ALND. The second aim was to analyze whether the number of SLNs removed was associated with an increased incidence of postoperative morbidity. Methods From Apr-2006 to Aug-2007, 140 patients treated with SLNB and 81 patients treated with ALND were enrolled in the study. Patients' data were collected preoperatively and at 1, 6, and 12 months after operation. Measurement of arm volume and shoulder function, evaluation of subjective sensory abnormality of both arms and chest wall were performed at every follow-up visit. Besides, patients were required to fill out the simplified Chinese version of the functional assessment of cancer therapy-breast questionnaire at 12 months after operation. Results Patients treated with SLNB suffered less morbidity compared with ALND. Elevated body mass index and ALND procedure were independent risk factors associated with postoperative lymphedema. Moreover, patients treated with wide local excision or SLNB had better QoL compared with those treated with mastectomy or ALND. No relationship was observed between the number of SLNs and the morbidity or QoL. Conclusion SLNB is associated with a better QoL and less morbidity compared with ALND regardless of the number of SLNs in Chinese women with breast cancer. To limit the number of SLNs less than five did not show any evidence to reduce morbidity.

Avaliação das compensações linfáticas no pós-operatório de câncer de mama com dissecção axilar através da linfocintilografia

O sistema linfático é um componente do corpo humano intimamente relacionado ao sistema venoso. Entretanto, o conhecimento científico a seu respeito é limitado. A etiologia e os fatores de risco para o desenvolvimento do linfedema no pós-operatório de câncer de mama são multifatoriais e ainda não foram completamente esclarecidos. O objetivo desta revisão da literatura foi descrever o padrão linfocintilográfico e avaliar as compensações linfáticas do membro superior no pós-operatório de câncer de mama com dissecção axilar.

Penoplasty for buried penis in infants and children: report of 100 cases

The aim of this study is to report single surgeon's experience in treatment of buried penis in children and describe the surgical technique which was developed by the senior author. Described surgical technique avoids circumferential incision at the base of the penis and thus prevents formation of post-operative lymphedema. Repair is based on a vertical incision in median raphe, complete degloving of penis and tacking its base to prepubic fascia. Shaft skin is attached to base of penis with vertical mattress sutures. Patient age varied from 1 month to 11.4 years (mean 1.9 years). All patients had good to excellent outcome with uniformly improved visualization of penile shaft post-operatively. There was one case of wound infection successfully treated with oral antibiotics. Revisions were needed in 4% patients. Surgical correction of buried penis in infants and children is safe and effective. Described technique is applicable for essentially all cases of congenital buried penis as well as for iatrogenically entrapped penis after circumcision. In our experience there were no additional procedures required to assure skin coverage of penile shaft.

Inguinal lymphadenectomy combined with staging endoscopic pelvic node sampling for stage III melanoma

Elective pelvic lymphadenectomy is one of the enduring controversies in the management of Stage III melanoma of the groin. It can provide valuable staging information but concerns remain over the possibility of increased morbidity without the benefit of increased survival. Endoscopic lymphadenectomy of the pelvic nodes is an established procedure in the management of urological and gynaecological malignancy but is relatively novel in the management of metastatic melanoma. An endoscopic approach reduces the risks suggested to be associated with the open procedure while still providing the clinician with the benefit of improved staging information. The authors present their experience of a combined procedure in a series of eight patients undertaken between January 2005 and May 2006 at the Exeter Melanoma Unit. One patient was discovered to harbour occult pelvic nodal metastases, despite a negative pre-operative CT scan. While no complications were directly attributable to the endoscopic procedure, the only major complication was post-operative lymphoedema which occurred in one case. The authors' experience suggests a combined procedure is both feasible and safe in the Plastic Surgery Department setting for the management of Stage III melanoma of the groin. This is the first documented UK experience of this technique.

Quality of Life and Disability after Ilio-Inguinal Lymphadenectomy

Aim: to examine and report the quality of life together with the level of disability of cancer patients who underwent therapeutic ilio-inguinal lymphadenectomy.Materials and methods: the complete files of 62 patients who underwent 66 procedures between January 1990 and November 2006 were obtained and analysed retrospectively. Data concerning postoperative complications, presence and extent of lymphoedema, physical symptoms, duration of disability, daily life and social activities were collected through a specific questionnaire and reviewed.Results : early postoperative complications occurred in 36% of cases. Sixty-five percent of patients developed some degree of postoperative lymphoedema. Twenty patients suffered at least one episode of erysipelas. Median postoperative disability was 4 months (range 1.5 to 24 months). Among the active population, 8 patients (18%) never returned to work. Postoperative quality of life was good or very good for most patients, with acceptable limitation in daily activities. Conclusion : ilio-inguinal lymphadenectomy is the only radical procedure able to provide long-term tumour control and maintain a good to very good quality of life, thus providing a real possibility of returning to work.

Angiosarcoma Arising in an Unirradiated Breast with Subsequent Pituitary Metastasis

Angiosarcoma of the breast is a rare condition with known risk factors. The Stewart-Treves syndrome describes angiosarcoma of the arm or breast in the setting of adjuvant radiation therapy (RT) after breast conservation surgery. Angiosarcoma of the breast, in the absence of RT, is rarer still. We present a unique case of angiosarcoma of the breast, diagnosed 6 years after conservative surgery for carcinoma of the breast when no adjuvant RT was given. Chronic postoperative lymphoedema in the breast delayed the investigation of skin changes, with an eventual diagnosis of angiosarcoma. An isolated pituitary metastasis 9 months from the diagnosis, the first such reported case, adds to the complexity of the case. The diagnosis and management of angiosarcoma of the breast is discussed. Angiosarcoma is a rare occurrence after breast conservative surgery. Postoperative lymphoedema can impede early diagnosis. The disease can display unique metastatic potential

2093 POSTER Detection of postoperative lymphoedema in patients with breast cancer

2093 POSTER Detection of postoperative lymphoedema in patients with breast cancer

QOL Evaluation of the Patient who Developed Breast Cancer Postoperative Lymph Edema

QOL Evaluation of the Patient who Developed Breast Cancer Postoperative Lymph Edema

352 POSTER Detection of postoperative lymphoedema by Multiple Bioelectric Impedance Analysis in breast cancer

352 POSTER Detection of postoperative lymphoedema by Multiple Bioelectric Impedance Analysis in breast cancer

A method for the detection of post-operative lymphoedema after operation for breast cancer: multifrequency bioelectrical impedance analysis

Lymphoedema, a pathological accumulation of extracellular water (ECW), is a severe post-operative complication. Multifrequency bioimpedance analysis (MFBIA) is a method for the detection of changes in ECW. Our aim is to establish the methodology of MFBIA and to apply it on to group of patients undergoing breast cancer surgery.We measured a control group of 60 women, another group of 5 women with pronounced lymphoedema and a group of 36 patients undergoing breast cancer surgery during a 9-month period after surgery using MFBIA and circumferential measurements for recording volume changes in the upper limb. Different linear extrapolations from 1, 5, 50, 100, 200 kHz were determined to find resistance at 0 Hz for each patient; ratios of R0 were evaluated for non-dominant/dominant and non-operated/operated limbs. Pearson's correlation coefficient was used to compare the correlation between the results and patient characteristics.Extrapolation using 5, 50, 100 kHz had the lowest standard deviation. Within the patients with pronounced lymphoedema, bigger differences were found by MFBIA as compared with circumference measurements. A stronger correlation between limb volumes calculated from circumference measurements with weight and BMI as compared with MFBIA was found. Lymphoedema was found in 14 women in the tested group. The best association between patients' subjective symptoms was with the MFBIA measurement.

Lymphedema is common among post-operative cancer survivors

18524 Background: Lymphedema (LE) is associated with the surgical treatment of a number of tumors and is a serious long-term condition with significant medical, economic, and quality of life consequences. Early detection and management are critical to preventing LE progression and complications. We examined the literature to ascertain the incidence and identify factors associated with an increased postoperative risk for LE. Methods: We systematically reviewed the oncology literature (1972–2005) to identify studies that examined postoperative LE. Data pertaining to the type of malignancy, the surgical procedure performed, the criteria used to define LE, and the median follow-up time were extracted. The incidence of LE was summarized using weighted averages. Results: We identified a total of 122 reports of postoperative LE (N = 24,095 patients), which were broken down by cancer type as follows: breast cancer (n = 45), melanoma (n = 31), gynecologic (GYN) malignancies (n = 30), genitourinary (GU) malignancies (prostate n = 6, penile n = 6, bladder n = 2), and sarcoma (n = 2). When only prospective studies (n = 74, 61%) were considered, the incidence of LE following axillary node dissection (AND) in patients with breast cancer was 19% compared with 8% following AND for melanoma. The incidence of lower extremity LE following inguinofemoral and/or pelvic lymph node dissection for melanoma was 30% compared with 24%, 14%, and 20% for GYN malignancies, GU malignancies and sarcomas. The relative risk of postoperative lower extremity LE increased two-fold in patients who received radiation therapy. Methods of measuring LE included extremity circumference (n = 17 studies) with various defined thresholds (&gt;1 cm [n = 8], &gt;2 cm [n = 7], and &gt;3 cm [n = 2]). Fourteen studies used volume measurements, while the remainder used an ad hoc clinical grading method. The lowest incidence of LE was seen in studies with the shortest follow-up. Conclusions: LE is a common condition resulting from the surgical treatment of a number of different malignancies. To enhance the quality of postoperative care in cancer survivors, objective LE measurement and symptom assessment should be part of standard practice during both early and long-term follow-up. No significant financial relationships to disclose.

Die V.A.C.® (Vacuum Assisted Closure™) Therapie als Behandlungsalternative bei Komplikationen nach Durchführung einer Lymphadenektomie bei fortgeschrittenen Peniskarzinomen

Penile cancer is a rare tumor entity. Primary therapy consists of tumor excision (laser therapy, circumcision, partial or complete penectomy). Therapy of advanced or metastasized penile cancer is still challenging due to high morbidity with postoperative lymph edema, fistula, wound infection and resulting secondary wound healing. In this series we retrospectively investigated clinical and diagnostic data from 28 patients (1995-2005) with penile cancer regarding their follow-up, especially in respect to morbidity after lymphadenectomy and the resulting therapy. We evaluated the efficacy of V.A.C. therapy as an alternative in this setting regarding costs and duration of hospital stay. 11/28 pats. underwent lymphadenectomy (LA) because of tumor stage or suspicious lymph node status. Eight of those pats. developed complications, as there were: lymph edema, and/or secondary wound healing with fistula. 4/8 pats. were treated with V.A.C. therapy. In this group a significant advantage regarding cost and time of hospitalization was observed. Despite higher primary introduction costs an early V.A.C. therapy in patients with secondary wound healing and lymph obstruction is advisable and resulted in a shortened hospitalization and reduced overall costs per patient.

Reduction of Postoperative Lymphedema after Oral Tumor Surgery with Sodium Selenite

The objective of this double-blind, randomized study was to establish whether sodium selenite administered orally or intravenously reduces postoperative lymphedema after oral tumor surgery and to study the effect of sodium selenite on glutathione peroxidase (GPX) activity and oxygen radical production. Twenty patients were enrolled in the study. Each of the participants received 1,000 microg sodium selenite intravenously or orally daily for 3 wk during the pre-, intra-, and postoperative period. The extent of lymphedema was measured for 2 wk and the plasma and whole-blood selenium concentration, GPX, reactive oxygen species (ROS), NO, and malonic dialdehyde were measured for 1 yr postoperatively. There was an inverse correlation between the severity of the lymphedema and the whole-blood/plasma selenium concentration and GPX activity. In addition, a positive correlation between the ROS concentration and the extent of lymphedema was observed. A significant reduction of lymphedema occurred in the sodium selenite-treated group. It is concluded that sodium selenite represents a suitable adjuvant treatment of secondary lymphedema in surgically treated patients with tumors in the oral and maxillofacial areas. Treatment with sodium selenite is especially advantageous as it can be instituted immediately after surgery prior to wound healing when manual lymphatic decongestion therapy cannot be applied.

Radiation therapy for low-grade soft tissue sarcoma.

One hundred eight patients with low-grade soft tissue sarcoma treated at the authors' institution from 1984 to 1999 were reviewed retrospectively. Low-grade sarcomas were defined as those designated as Grade I of III or Grade I or II of IV. Patients who presented with recurrent tumors or who had multiple procedures at outside institutions were excluded. The patient's gender, age at diagnosis, histologic diagnosis, site and depth of primary involvement, and specimen size at resection were noted. Involvement of periosteum, bone, and neurovascular structures also was recorded. The decision to use radiation therapy was made case-by-case. Indications for preoperative radiation therapy included tumor adjacent to the neurovascular bundle or bone where a marginal surgical margin was anticipated. Indications for postoperative radiation therapy included followup resection of an unsuspected malignancy. Patients were evaluated according to treatment rendered. Sixty-six patients were treated with surgery alone, whereas 42 patients had excision of the tumor in conjunction with radiation therapy. The overall local control rate was 97.2% (105 of 108). There were no statistically significant differences in local recurrence, wound complication, fibrosis, or survival between the two groups. Patients treated with radiation therapy had an increased incidence of postoperative lymphedema. Kaplan-Meier 10-year survival rates were approximately 90% for both groups.

A key to understanding postoperative lymphoedema: a study on the evolution and consistency of oedema of the arm using ultrasound imaging

Post-mastectomy oedema is a very serious complication that, in the course of time, will transform into fibrotic tissue. The aim of our study is to evaluate when and in which layer liquid oedema transforms into fibrotic tissue. To do so, ultrasonographic images were taken of 22 patients and 9 control women at the shoulder and 10 cm proximal and distal from the olecranon, with the images then being scanned and imported into a computer program to determine echogenicity of the dermis, subcutis, subcutis on dermal side and subcutis on fascial side. Statistical analyses were performed by means of the Wilcoxon test and a Student's t -test. No significant differences (P≤0.05) were found for the different parameters in the control group. In the experimental group: significant differences in perimeter, skinfold, thickness of dermis and subcutis were found. Although not significant, subcutaneous tissue was more echogenic on the oedematous side, with significant hyperechogenicity at the fascial subcutaneous layer. This indicates that fibrotic tissue develops distally in the forearm.