Risk factors for arm lymphedema following breast cancer diagnosis in Black women and White women

Risk factors for arm lymphedema following breast cancer diagnosis in Black women and White women

Breast Cancer Res Treat. 2008 Feb 24

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.

SpringerLink

A Way to Help Prevent Arm Lymphedema - Fine Needle Aspiration

Accuracy of fine-needle aspiration cytology of axillary lymph nodes in breast cancer patients: a study of 115 cases with cytologic- histologic correlation.

Cancer. 2008 Feb 19 Alkuwari E, Auger M.
Department of Pathology, McGill University Health Center, McGill University, Montreal, Quebec, Canada.

BACKGROUND: Fine-needle aspiration (FNA) cytology of axillary lymph nodes is a simple, minimally invasive technique that can be used to improve preoperative determination of the status of the axillary lymph nodes in patients with breast cancer, thereby serving as a tool with which to triage patients for sentinel versus full lymph node dissection procedures. The aim of the current study was to determine the sensitivity and specificity of FNA cytology to detect metastatic breast carcinoma in axillary lymph nodes.

METHODS: A total of 115 FNAs of axillary lymph nodes of breast cancer patients with histologic follow-up (subsequent sentinel or full lymph node dissection) were included in the current study.

The specificity and sensitivity, as well as the positive and negative predictive values, were calculated.

RESULTS: The positive and negative predictive values of FNA cytology of axillary lymph nodes for metastatic breast carcinoma were 1.00 and 0.60, respectively. The overall sensitivity of axillary lymph node FNA in all the cases studied was 65% and the specificity was 100%. The sensitivity of FNA was lower in the sentinel lymph node group than in the full lymph node dissection group (16% vs 88%, respectively), which was believed to be attributable to the small size of the metastatic foci in the sentinel lymph node group (median, 0.25 cm). All false-negative FNAs, with the exception of 1 case, were believed to be the result of sampling error. There was no 'true' false-positive FNA case in the current study.

CONCLUSIONS: FNA of axillary lymph nodes is a sensitive and very specific method with which to detect metastasis in breast cancer patients. Because of its excellent positive predictive value, full axillary lymph node dissection can be planned safely instead of a sentinel lymph node dissection when a preoperative positive FNA result is rendered. Cancer (Cancer Cytopathol) 2008. (c) American Cancer Society.

PMID: 18286535 [PubMed - as supplied by publisher]

GROUNDBREAKING MEDICARE APPEALS COUNCIL DECISION COMPRESSION GARMENTS USED IN LYMPHEDEMA TREATMENT MEET MEDICARE DEFINITION OF PROSTHETIC DEVICES

GROUNDBREAKING MEDICARE APPEALS COUNCIL DECISION COMPRESSION GARMENTS USED IN LYMPHEDEMA TREATMENT MEET MEDICARE DEFINITION OF PROSTHETIC DEVICES

On February 20, 2008 a Medicare Administration Appeals Judge affirmed an earlier Administrative Law Judge's determination that compression garments used as part of the medical treatment of lymphedema meet the definition of “prosthetic devices” in the Social Security Act, and are coverable by Medicare.

This most recent case follows two earlier cases where the Appeals Council reversed two different ALJs who supported providers who denied reimbursement based on the unsubstantiated claim that compression garments “were not covered by Medicare”. Three other ALJs decided in favor of three different Medicare Beneficiaries, finding that the compression bandages, sleeves, stockings, devices and directional flow garments were medically necessary and coverable in the treatment of lymphedema as “prosthetic devices”.

Unfortunately these cases are not precedent-setting, and there is no desire by the Centers for Medicare and Medicaid Services (CMS) to change their medically unsound policies. CMS has also recently denied a formal request to change their HCPCS Coding manual to recognize the function of these items in the treatment of lymphedema, and to code them as prosthetic devices.

What actions can be taken to move CMS into action?

Every denial of compression bandages or compression garments must be appealed by the patient. The procedures for appeal are found in the denial letter. The appeal process will involve a redetermination appeal and a reconsideration appeal to Medicare Administrative Contractors, who will side with the denial, and then to an Administrative Law Judge where a fair hearing can be obtained.

Every lymphedema supply manufacturer must make a formal request to CMS for a recoding of their products with an “L-Code” as prosthetic devices when used in the treatment of lymphedema.

And every affected citizen, whether suffering for or at risk for lymphedema must write his of her Congress Member requesting that CMS revise their policies to cover the treatment of lymphedema according to current standards.

Since CMS has refused repeatedly to even consider a change, urge your legislator to consider sponsoring the proposed “Lymphedema Diagnosis and Treatment Cost-Saving Act” which has been presented to legislators over the last 5 years.

I am prepared to help in all these matters, and have materials which will be helpful. Please contact Robert Weiss at: LymphActivist@aol.com

Lymphatic venous anastomosis (LVA) for treatment of secondary arm lymphedema.

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.
Breast Cancer Res Treat. 2008 Feb 13
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.

Keywords

Lympho-venous anastomosis (LVA) - Microsurgery - Evidence-based medicine - Lymphoscintigraphy - Inverse water volumetry - Review - Breast cancer related lymphedema

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.

Springer Link

Lymphedema in the morbidly obese patient: unique challenges in a unique population.

Lymphedema in the morbidly obese patient: unique challenges in a unique population.

Ostomy Wound Manage. 2008 Jan

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]

See also:

Obesity and Lymphedema

The Lymphedema Diet

The prognostic significance of facial lymphedema in HIV-seropositive subjects with Kaposi sarcoma.

The prognostic significance of facial lymphoedema in HIV-seropositive subjects with Kaposi sarcoma.

Jan 2008

Feller L, Masipa JN, Wood NH, Raubenheimer EJ, Lemmer J.

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.

Aids Research and Therapy