Lower Limb Lymphedema Common in Survivors of Gynecological Cancer

Lower Limb Lymphedema Common in Survivors of Gynecological Cancer

NEW YORK JUN 27, 2007 (Reuters Health) - A significant proportion of gynecological cancer survivors develop lower limb lymphedema, according to results of a study published in the June 15th issue of Cancer.

"Lower limb lymphedema is one of the most disabling side effects of surgical and radiotherapy treatment for gynecological cancer," note Dr. Vanessa Beesley, of the Queensland Institute of Medical Research, Australia, and colleagues. "For many gynecological cancer patients, lymph node dissection is an integral part of cancer treatment and surgical staging, and this procedure has been associated with lymphedema development."

The researchers conducted a population-based cross-sectional mail survey of gynecological cancer survivors in 2004. The questionnaire, which was completed by 802 women, included items on demographics, supportive care needs, and lymphedema-related needs.
Overall, 10% of subjects reported a diagnosis of lymphedema. Another 15% reported undiagnosed symptomatic lower leg swelling. The prevalence of diagnosed lymphedema was higher among survivors of vulvar cancer (36%) than all other gynecological cancer subgroups.
Multivariate analysis revealed that for cervical cancer survivors, the odds of developing lower limb swelling were 3.5 times higher if they had radiotherapy and 3.3 times higher if they had lymph nodes removed. The odds of developing lymphedema were higher for survivors of uterine and ovarian cancer who had lymph node dissection or who were overweight or obese.

"Whereas 31% reported being informed about lymphedema before their cancer treatment, 34% of women did not recall being informed about this condition until they were diagnosed," Dr. Beesley and colleagues report. "Others (30%) were informed after their cancer treatment but before symptoms arose, or they could not remember when they were informed (5%)."

The researchers note that supportive care needs in the information and symptom management domains were higher in gynecological cancer survivors with lymphedema than in those with no swelling.

"Women at risk for lymphedema would benefit from instructions about early signs and symptoms and provision of referral information," the team concludes.

SOURCE:

Cancer 2007;109:2607-2614.

Cancer Page

Complete decongestive therapy for arm lymphedema

Efficacy of complete decongestive therapy and manual lymphatic drainage on treatment-related lymphedema in breast cancer.

Int J Radiat Oncol Biol Phys. 2007 Mar Koul R, Dufan T, Russell C, Guenther W, Nugent Z, Sun X, Cooke AL. Department of Radiation Oncology, CancerCare Manitoba, Winnipeg, MB, Canada. rashmi.koul@cancercare.mb.ca

OBJECTIVE: To evaluate the results of combined decongestive therapy and manual lymphatic drainage in patients with breast cancer-related lymphedema.

METHODS AND MATERIALS: The data from 250 patients were reviewed. The pre- and posttreatment volumetric measurements were compared, and the correlation with age, body mass index, and type of surgery, chemotherapy, and radiotherapy was determined. The Spearman correlation coefficients and Wilcoxon two-sample test were used for statistical analysis.

RESULTS: Of the 250 patients, 138 were included in the final analysis. The mean age at presentation was 54.3 years. Patients were stratified on the basis of the treatment modality used for breast cancer management. Lymphedema was managed with combined decongestive therapy in 55%, manual lymphatic drainage alone in 32%, and the home program in 13%. The mean pretreatment volume of the affected and normal arms was 2929 and 2531 mL. At the end of 1 year, the posttreatment volume of the affected arm was 2741 mL. The absolute volume of the affected arm was reduced by a mean of 188 mL (p < p =" 0.0142)," p =" 0.0354),">

CONCLUSION: Combined decongestive therapy and manual lymphatic drainage with exercises were associated with a significant reduction in the lymphedema volume.

Keywords: Lymphedema, Breast cancer, Combined decongestive therapy, Manual lymphatic drainage

Red Journal

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Long-term management of breast cancer-related lymphedema after intensive decongestive physiotherapy.

Breast Cancer Res Treat. 2007 Mar

Vignes S, Porcher R, Arrault M, Dupuy A. Department of Lymphology, Hôpital Cognacq-Jay, Site Broussais, 102 rue Didot, 75014, Paris, France, stephane.vignes@hopital-cognacq-jay.fr.

Keywords: Breast cancer - Lymphedema - Physiotherapy - Compliance - Elastic garment - Low stretch bandage

BACKGROUND: Treatment of lymphedema is based on intensive decongestive physiotherapy followed by a long-term maintenance treatment. We analyzed the factors influencing lymphedema volume during maintenance treatment.

METHOD: Prospective cohort of 537 patients with secondary arm lymphedema were recruited in a single lymphology unit and followed for 12 months. Lymphedema volume was recorded prior to and at the end of intensive treatment, and at month 6 and month 12 follow-up visits. Multivariate models were fitted to analyze the respective role of the three components of complete decongestive therapy, i.e. manual lymph drainage, low stretch bandage, and elastic sleeve, on lymphedema volume during the 1-year maintenance phase therapy.

RESULTS: Mean volume of lymphedema was 1,054 +/- 633 ml prior and 647 +/- 351 ml after intensive decongestive physiotherapy. During the 1-year maintenance phase therapy, the mean lymphedema volume slightly increased (84 ml-95% confidence interval [CI]: 56-113). Fifty-two percent of patients had their lymphedema volume increased above 10% from their value at the end of the intensive decongestive physiotherapy treatment phase. Non-compliance to low stretch bandage and elastic sleeve were risk factors for an increased lymphedema after 1-year of maintenance treatment (RR: 1.55 [95% CI: 1.3-1.76]; P < p =" 0.002," p =" 0.91).">

CONCLUSION: During maintenance phase after intensive decongestive physiotherapy, compliance to the use of elastic sleeve and low stretch bandage should be required to stabilize lymphedema volume.

Springer Link

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Predictive factors of response to intensive decongestive physiotherapy in upper limb lymphedema after breast cancer treatment: a cohort study.

Breast Cancer Res Treat. 2006

Vignes S, Porcher R, Champagne A, Dupuy A. Department of Lymphology, Hôpital Cognacq-Jay, Université Paris, France. stephane.vignes@hopital-cognacq-jay.fr

Key words: breast cancer - lymphedema - physiotherapy - predictive factors

BACKGROUND: Lymphedema is a frequent complication after breast cancer treatment. Reduction of lymphedema volume is obtained during an intensive phase with daily physiotherapy. Response to treatment remains unknown prior treatment. We purposed to analyze predictors of response of lymphedema treatment throughout the first course of physiotherapy.

DESIGN: Patients with secondary arm lymphedema were recruited in a single lymphology unit between 2001 and 2004. For each patient, the following data were recorded: characteristics of breast cancer treatment, patient characteristics, body mass index and lymphedema volume prior and at the end of treatment.

RESULTS: Three hundred and fifty-seven women (mean age: 53+/-11 years) were included. Initial excess volume of lymphedema was correlated to body mass index and duration of lymphedema. Mean duration of intensive decongestive therapy was 11.8+/-3.3 days. Mean excess volume of lymphedema was 1067+/-622 ml prior treatment and 663+/-366 ml after treatment (p<0.001),>

CONCLUSION: Duration of lymphedema from cancer treatment and body mass index were the only two predictors of absolute reduction of lymphedema volume after intensive decongestive physiotherapy. For all patients this latter treatment is highly effective in management of secondary upper limb lymphedema after breast cancer.

Springer Link

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Breast cancer-related lymphedema--what are the significant predictors and how they affect the severity of lymphedema?

Breast J. 2006 Nov-Dec Soran A, D'Angelo G, Begovic M, Ardic F, Harlak A, Samuel Wieand H, Vogel VG, Johnson RR. Magee-Womens Hospital, Pittsburgh, Pennsylvania 15213, USA. asoran@magee.edu

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). The primary aim of this study was to determine the predictive factors of BC-related LE. The secondary aim was to investigate the impact of predictors on the severity of LE. The study design was intended to be a 1:2 matched case-control study. Instead, we stratified on age (+/-10 years), radiation therapy (y/n), and type of operation (SM/MRM/MRM with tram).

Patients who underwent BC surgery between 1990 and 2000 at UPMC Magee-Womens Hospital were reviewed for LE. Data were collected on 52 women with LE and 104 female controls. Logistic regression was utilized to assess the relationship between risk factors and LE. Ordinal logistic regression was performed to determine the association between risk factors and severity of LE.

Severity was defined according to the volume difference between affected and unaffected limbs. Risk factors considered were occupation/hobby (hand use), TNM stage, number of dissected nodes, number of positive nodes, tumor size, infection, allergy, diabetes mellitus, hypertension, hypothyroidism, chronic obstructive pulmonary disease, and body mass index (BMI). LE was mild in 43 patients and was moderate/severe in nine patients. The level of hand use in the control group was categorized as low in 56 (54%), medium in 15 (14%), and high in 33 (32%) patients.

The corresponding frequencies were 14 (33%), 6 (14%) and 23 (53%) for patients with mild LE and 3 (33%), 1 (11%), 5 (56%) for patients with moderate/severe LE (p <>

The results of this stratified case-control study demonstrated that the risk and severity of LE was statistically related to infection, BMI, and level of hand use.

Blackwell

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Complex decongestive physiotherapy for patients with chronic cancer-associated lymphedema.

J Formos Med Assoc.

2004 May Liao SF, Huang MS, Li SH, Chen IR, Wei TS, Kuo SJ, Chen ST, Hsu JC. Department of Physical Medicine and Rehabilitation, Changhua Christian Hospital, 135 Nanhsiao Street, Changhua 500, Taiwan.

BACKGROUND AND PURPOSE: Lymphedema of the limbs after cancer therapy is the most common cause of lymphedema in developed countries. There is no cure for chronic cancer-associated lymphedema. Multidisciplinary complex decongestive physiotherapy (CDP) is commonly used as a primary treatment. This prospective study assessed the efficacy of intensive CDP treatment in chronic cancer-associated lymphedema.

METHODS: Thirty women who had unilateral upper or lower limb chronic lymphedema after breast or pelvic cancer therapy were enrolled in the study. All patients received CDP once per day, in consecutive full treatment sessions, which took place between 4 and 21 times. Assessment of the results of therapy included measuring the circumference, calculated volume, and edema ratio (excess volume/unaffected side volume) of the limb volume. The main outcome measure was the percentage reduction in excess limb volume.

style="color:#ff6600;">RESULTS: The pretreatment edema ratio demonstrated a high correlation with the patient's age (r = 0.508, p = 0.004) and the duration of the lymphedema (r = 0.634, p <>

CONCLUSIONS: Intensive CDP was effectively able to reduce the limb volume of patients with chronic cancer-associated lymphedema. Further follow-up study is needed to confirm the effectiveness of CDP in the maintenance phase, and its long-term effectiveness in Taiwanese.

PMID: 15216399 [PubMed - indexed for MEDLINE]

Functional magnetic resonance evidence of cortical alterations in a case of reversible congenital lymphedema of the lower limb: a pilot study.

Functional magnetic resonance evidence of cortical alterations in a case of reversible congenital lymphedema of the lower limb: a pilot study.
Lymphology. 2007

Pardini M, Bonzano L, Roccatagliata L, Boccardo F, Mancardi G, Campisi C.

Magnetic Resonance Research Centre on Nervous System Diseases, University School of Medicine and Surgery, San Martino Hospital, Genoa, Italy. pardini82@yahoo.it

We report the first application of brain functional Magnetic Resonance Imaging (fMRI) to congenital peripheral lymphedema patients before and after microsurgical treatment. Our aim was to evaluate the effects of limb shape change on cortical organization of the motor system and how the cortical sensorimotor network restructures after microsurgical therapy. We acquired fMRI during active motor and motor imagery tasks before surgery and six months after surgery in a patient with congenital lymphedema of the left leg. fMRI data revealed activation differences in primary and secondary motor areas between the two scanning sessions for both tasks and also between the patient's and a healthy volunteer's activations. We suggest that these alterations could be related to changes in body schema representation due to the congenital lymphedema.

PMID: 17539461 [PubMed - in process]

Comparison of upper limb volume measurement techniques and arm symptoms between healthy volunteers and individuals with known lymphedema.

Comparison of upper limb volume measurement techniques and arm symptoms between healthy volunteers and individuals with known lymphedema.

Lymphology. 2007 Mar

Ridner SH, Montgomery LD, Hepworth JT, Stewart BR, Armer JM.

School of Nursing, Vanderbilt University, Nashville, Tennessee 37240, USA. sheila.ridner@vanderbilt.edu

Lymphedema is a problem for breast cancer survivors. The proliferation of limb measurement techniques makes it difficult to know how best to measure an at-risk limb. Using a sample of healthy volunteers and individuals with lymphedema, this study: 1) examined the relationship between more commonly used circumferential limb measurement methods and newer measurement methods of infrared laser perometry and bioelectrical impedance; 2) compared self-reported arm symptoms in healthy volunteers and breast cancer survivors with known lymphedema; and 3) explored the relationships among self-reported arm symptoms and circumferential tape measurement, infrared laser (perometry), and single and multi-frequency bioelectrical impedance.

Lymphedema index ratios were calculated to allow comparison among measurement methods. Measurement methods correlated strongly with each other. Fourteen symptoms were reported by one or more participants in the lymphedema group while participants in the healthy volunteer group reported only eight symptoms over the same time frames. Using p <>

Future research needs to include serial arm measurements to explore arm volume variation in healthy and lymphedema volunteers and to further investigate possible lymphedema index ratios cut points as lymphedema diagnostic criteria.

PMID: 17539463 [PubMed - in process]

Integrated management of filarial lymphedema for rural communities.

Integrated management of filarial lymphedema for rural communities.

Lymphology. 2007 Mar
Narahari SR, Ryan TJ, Mahadevan PE, Bose KS, Prasanna KS. Institute of Applied Dermatology, Kasaragod, India. srnarahari@satyam.net.in

The Global Alliance for the Elimination of Lymphatic Filariasis (GAELF) has recommended exploring local health traditions of skin care and a low cost treatment paradigm for rural communities has been proposed by Vaqas and Ryan. Our case study incorporates these promising treatments for use in treating filariasis in rural communities.

Patients having lymphedema of one or both lower limbs (skin: normal, thickened or with trophic/warty changes) received treatment components from ayurveda, yoga and biomedicine simultaneously: including soap wash, phanta soaking, Indian manual lymph drainage (IMLD), pre- and post-IMLD yoga exercises, and compression using bandages for 194 days, along with diet restrictions and oral herbal medicines indicated for "elephantiasis" in Ayurveda. Entry points when infected were treated with biomedical drugs.

The study was conducted in the reverse pharmacology design. 112 patients and 149 lower limbs completed 194 days of treatment during 2003-2006. Significant improvements were observed in the limb circumference measurements and the frequency of acute dermatolymphangioadenitis, use of preventive antibiotics, and reduction in the number of entry points were also improved.

The objective to obtain significant benefit for a common problem using locally available, sustainable and affordable means has been achieved. It has not been our purpose to show that the regimen employed is better than another but the results do pose the question--"Are there components of Ayurvedic medicine that deserve further study?"

It is important to understand that the regimen has been delivered mostly at home and that participants we have treated, representing a population suffering from a common problem, have not had access to effective conservative therapy that is culturally acceptable, safe, and efficacious.

PMID: 17539459 [PubMed - in process]

Upper extremity lymphedema after treatment for breast cancer: a review of the literature.

Upper extremity lymphedema after treatment for breast cancer: a review of the literature.

Ostomy Wound Manage. 2007 May
Dow Meneses K, McNees MP.

College of Nursing, University of Central Florida, Florida;Email: kdow@mail.ucf.edu.

Upper extremity lymphedema - a common, poorly understood, and relatively understudied complication of cancer therapy - is a progressive and debilitating condition for which no cure is available. While advances in cancer treatment have lowered the incidence of lymphedema, lymph node trauma is often inevitable and the number of cancer survivors and elderly are increasing. A review of the literature suggests that research is needed to better understand the incidence and magnitude of upper extremity lymphedema; develop reliable and valid lymphedema risk assessment instruments; improve collaborative research efforts among skin, wound, and cancer investigators; and develop evidence-based lymphedema prevention and treatment protocols. Currently available evidence also indicates that increased clinician and patient awareness and education may help reduce the risk of lymphedema-associated complications through early detection and prompt interventions.

PMID: 17551172 [PubMed - in process]

Upper limb swelling following mastectomy: lymphedema or not?
Oncology (Williston Park). 2007 Apr

Armer J.
Sinclair School of Nursing, University of Missouri at Columbia, USA.

Having experienced an excisional biopsy, sentinel lymph node biopsy, and mastectomy, BH is at lifetime risk of developing post-breast cancer lymphedema in the arm on the side where her breast cancer was treated. She has two additional risk factors, among those documented in the literature: history of an infection (specifically a systemic infection, significant in that it required hospitalization for intravenous antibiotics) in the postsurgery period, and a moderate increase in bilateral limb volume and weight (body mass index) over the months and years following the breast cancer diagnosis. Further, the patient-reported transient hand swelling on the affected side and gradual weight increase are cues indicating a need for patient vigilance and careful monitoring by the health-care team. Preventing future infections, managing weight at an optimal level, and preventing trauma or injury to the affected arm and chest are important self-management precautions to reduce risk of chronic lymphedema development. BH needs continued support in reviewing evidence-based risk-reduction guidelines and understanding ways to apply them to her lifestyle.

In the absence of preoperative baseline or contralateral limb measurements (with circumferences or perometry or water displacement), assessment of limb change at a level identified as diagnostic of lymphedema (commonly, 200-mL volume or 2-cm girth increase from baseline or as compared to the contralateral limb) is very challenging. Without bilateral preop limb measurements for baseline and contralateral limb comparisons, BH might have been diagnosed with lymphedema at postop or at 48 months, when both limbs increased symmetrically. Symptom assessment is also crucial, as symptom report of heaviness and swelling is found to be associated with limb volume changes indicative of lymphedema.

Transient hand swelling may be evidence of latent lymphedema and cause for increased risk-reduction education and vigilance in assessment for emergence of nonresolving chronic lymphedema. million American women are breast cancer survivors.

According to the American Cancer Society, every person treated for cancer with lymph node removal, surgery, or radiation has a lifetime risk for lymphedema, swelling caused by an increase in protein-rich interstitial fluid. Some will develop lymphedema soon after cancer treatment (within weeks or months) and others may not experience.

PMID: 17508496 [PubMed - in process]

Lymphedema: an unusual complication of sirolimus therapy

Lymphedema: an unusual complication of sirolimus therapy
May 2007

Al-Otaibi T, Ahamed N, Nampoory MR, Al-Kandari N, Nair P, Hallm MA, Said T, Samhan M, Al-Mousawi M.
Hamed Al-Essa Organ Transplant Centre, Kuwait.

INTRODUCTION: Lymphedema is an increasingly observed complication of sirolimus (SIR) therapy. In this report, we describe four renal recipients with SIR-induced lymphedema of varying severity.

CASES REPORTS: Patient 1, a 38-year-old man developed lymphedema of the left upper limb after being exposed to SIR for 30 months (mean daily Rapamune dose, 3 mg; trough level, 10-18 ng/mL). Venography and duplex ultrasound were normal. Lymphangiography was showed delayed lymphatic drainage. SIR was replaced with Prograf with significant improvement in the lymphedema over the next 6 months. Patient 2, a 26-year-old woman, developed lymphedema of the left lower limb at 24 months after starting SIR (mean daily dose, 3 mg; trough level, 10-15 ng/mL). Lymphangiography showed delayed drainage of lymphatics in the left lower limb. The patient was shifted to Prograf and there was some improvement over the next 4 months. Patient 3, a 28-year-old man, developed lymphedema of the left upper limb at 24 months after the start of SIR (mean daily dose, 2 mg, trough level, 6-15 ng/mL). Lymphangiography showed evidence of lymphatic obstruction. SIR was changed to cyclosporine with only mild improvement in lymphedema over the next 6 months. Patient 4, a 46-year-old man, developed lymphedema of the right upper limb at 7 months after starting SIR (mean daily dose, 6 mg; trough level, 10-16 ng/mL). Lymphangiography showed complete blockage of the lymphatic channels. SIR was changed to cyclosporine and there was mild improvement in lymphedema over the next 8 to 10 months.

CONCLUSION: The exact mechanism of SIR-induced lymphedema is unknown. The absence of other demonstrable etiologies and spontaneous improvement after discontinuation of SIR suggest that this drug was the responsible factor in these four patients. It occurred 7 to 30 months after transplantation. This is the fourth such report in the literature to the best of our knowledge.

ELSEVIER

Lymphedema associated with sirolimus in renal transplant recipients.

Severe limb lymphedema in sirolimus-treated patients.

Transplant Proc. 2005 Mar

Romagnoli J, Citterio F, Nanni G, Tondolo V, Castagneto M. Department of Surgery, Organ Transplantation, Policlinico Gemelli, Rome, Italy.

We report two kidney transplant recipients who developed severe limb lymphedema under sirolimus (SRL) immunosuppression. The patients received SRL 10 and 2 mg/d to achieve target levels of 10 to 20 ng/mL with tapering doses of prednisone. Renal function and drug levels were monitored monthly. Patient 1 developed lymphedema of the left upper limb 3 years posttransplantation, after having been exposed to high SRL doses in the preceding 2 years (mean SRL dose-9.5 mg/d, mean trough level-26.3 ng/mL, mean serum creatinine-1.63 mg/dL). In patient 2 lymphedema of both upper and lower right limbs occurred 18 months posttransplantation (mean SRL dose-3.2 mg/d, mean trough level-8.8 ng/ mL, mean serum creatinine-2.9 mg/dL).

Hypercholesterolemia and hypertriglyceridemia were also observed in both patients before SRL reduction/conversion. No signs of hematopoietic toxicity were observed. In both patients magnetic resonance (MR) angiography of the limb was negative for vascular obstruction, and lymphoscintigraphy revealed lymphatic obstruction. In patient 1 lymphedema improved significantly following SRL reduction and lymphatic drainage massage therapy. Patient 2 was converted to cyclosporine (CsA) improving markedly after conversion. Hypercholesterolemia and hypertriglyceridemia also improved significantly in both patients after reduction/conversion.

We conclude that SRL may facilitate the occurrence of lymphatic obstruction by mechanisms that are presently unexplained. Lymphedema of the limbs in renal transplant recipients under SRL treatment, especially if on the same side as the hemodialysis access, should warn the transplant physician to rapidly reduce or withdraw SRL before the occurrence of complete obstruction.

Transplantation Proceedings