Arm swelling after breast cancer surgery common

Arm swelling after breast cancer surgery common

Thu Aug 7, 2008 11:58am EDT

By Megan Rauscher

NEW YORK (Reuters Health) - Following surgery for breast cancer, many women will experience arm swelling - a bothersome condition doctors refer to as lymphedema.

Lymphedema is a public health issue "deserving greater attention," doctors from Australia wrote in a recently published paper.

Among 287 women with breast cancer, 190 took part in all assessments during 18 months of follow-up after surgery and arm swelling developed in 62 (33 percent) of them during that time, Dr. Sandra C. Hayes and colleagues from Queensland University of Technology in Kelvin Grove found.
Roughly 60 percent of these women had fleeting symptoms, whereby the lymphedema dissipated with or without treatment. However, 40 percent of women experienced long-term arm swelling lasting more than 3 months, with or without intermittent periods of relief.

Women with lymphedema, 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," she noted.

More extensive breast surgery increased the odds of lymphedema six-fold and having more than 20 cancerous lymph nodes removed increased odds four-fold.

Hayes noted that two identified risk factors for arm swelling post-surgery -- insufficient physical activity and not using 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," Hayes said.

SOURCE: Journal of Clinical Oncology, July 20, 2008.

11th Annual Georgia Lymphedema Education & Awareness Program

11th Annual Georgia Lymphedema Education & Awareness Program

An educational and awareness conference for patients, caregivers and professionals!

at: Piedmont Hospital

Richard H. Rich Auditorium

1968 Peachtree Road, NW, Building 77

Atlanta, Georgia

Saturday, October 18, 2008

7:30 am - 5:30 pm

Program includes:

What to expect of tissue after radiation? What is the physiology response of radiation? What does radiation do to the lymph nodes? - Peter Rossi, MD

How does vascular flow affect the lymphatics? - Ken Harper, MD

Expectations of surgery. - Christopher Hart, MD, FACS

The Lymphatic System, Wound Care, Infections and Treatment - Paula Stewart, MD

Parent Networking

Aquatic Exercises

The Connection of obesity and increased swelling in people with lymphedema and lipedema and more.

Additional information and registration form: Registration Form

Lighthouse Lymphedema Network

See you there

Toe bandaging for lymphedema and venous ulceration.

Toe bandaging for lymphoedema and venous ulceration.
Br J Nurs. 2008 Apr 10-23

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 - in process]

Advocates for Lymphedema

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Join us today to learn about, for daily discussions and for advocacy on behalf of lymphedema.

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Lymphedema People / Advocates for Lymphedema

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Cystic lymphangioma: An unusual cause of lower limb lymphedema.]

Cystic lymphangioma: An unusual cause of lower limb lymphedema.

J Mal Vasc. 2008 Jul 3

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.

EM/Consulte

Relationship between lymphoscintigraphy and clinical findings in lower limb lymphedema (LO): toward a comprehensive staging.

Relationship between lymphoscintigraphy and clinical findings in lower limb lymphedema (LO): toward a comprehensive staging.
Lymphology. 2008 Mar

Pecking AP, Albérini JL, Wartski M, Edeline V, Cluzan RV.
Department of Nuclear Medicine, Centre René Huguenin, Saint-Cloud, France. pecking_ap@yahoo.com

Although radionuclide lymphoscintigraphy (RNL) is widely used diagnostically for patients with lymphedema (LE), it has not been utilized for LE staging, which is still based upon clinical findings. The aim of this work is to establish whether the results of both conventional RNL and fusion imaging obtained from hybrid detectors may be used for a comprehensive clinicoimaging staging in LE. Radiolabeled nanocolloids (0.2 ml) were subcutaneously injected in 4,328 patients (23-78 years) with clinical lower limb LE and without venous disease. Patients were classified according to the ISL classification and had a minimal follow-up of 2 years. Images were taken 60 minutes after the injection as a whole body scanning and fusion images of functional SPET and anatomical CT. Clinical and RNL results were not in accordance, and a specific RNL staging was established. The association of clinical and functional staging yields a new method to grade LE patients, and this staging correlated with treatment efficacy. RNL is an important tool in lymphology, and its association with the clinical evaluation offers a new grading system which may be able to delineate patients with good prognosis, patients at risk for a complex decongestive physiotherapy (CDP) failure, and patients who may benefit from other therapeutic protocols.

PubMed

Candidate gene analysis in primary lymphedema

Candidate gene analysis in primary lymphedema
Lymphat Res Biol. 2008

Ferrell RE, Kimak MA, Lawrence EC, Finegold DN.
University of Pittsburgh, Department of Human Genetics, Pittsburgh, Pennsylvania.

Abstract Background: Primary lymphedema, the accumulation of protein-rich fluid in the interstitial space, is the clinical manifestation of mutations involved in lymphatic development and function. Mutations in three genes, VEGFR3, FOXC2, and SOX18, cause primary lymphedema. However, mutations in these three genes only account for a fraction of primary lymphedema. To identify other genes mutated in primary lymphedema, we resequenced twenty-five biologically plausible candidate genes for lymphedema in a large collection of primary lymphedema families.

Methods and Results: Candidate genes were selected on the basis of gene expression in lymphatic endothelial cells, differential antigenic expression in lymphatics, and mouse studies of lymphatic development. The gene sequence was downloaded from GenBank and sequence primers designed to amplify 1 Kb of the 5' sequence, exons and flanking intron-exon boundaries, and 500 bp of the UTR of each gene. No common causative mutations were observed among the 25 genes screened.

Single mutations were observed in elastin microfibril interfacer (EMILIN1), lymphocyte cytosolic protein 2 (LCP2), fatty acid binding protein 4 (FABP4), protein tyrosine kinase SYK (SYK), neuropilin-2 (NRP2), SpSRY-box 17 (SOX17), vascular cell adhesion molecule 1 (VCAM1), ROR orphan receptor C (RORC), and vascular endothelial growth factor B (VEGFB). Among these, the mutations in EMILIN1, RORC, LCP2, SYK, and VEGFB failed to segregate with lymphedema. The mutations in FABP4 (2), NRP2, SOX17, and VACM1 are consistent with being causative mutations, but occur in families too small to convincingly confirm cosegregation of mutation and phenotype.

Conclusion: We excluded mutation in 21 biological candidate genes as a common cause of primary lymphedema. Mutations in FABP4, NRP2, SOX17 and VCAM1 are consistent with causality and follow up of these four genes are warranted. The evidence for FABP4 harboring lymphedema mutations is discussed.

Mary Ann Liebert

HGF and MET Mutations in Primary and Secondary Lymphedema.

HGF and MET Mutations in Primary and Secondary Lymphedema.

Lymphat Res Biol. 2008

inegold DN, Schacht V, Kimak MA, Lawrence EC, Foeldi E, Karlsson JM, Baty CJ, Ferrell RE.
Department of Human Genetics, University of Pittsburgh, Pittsburgh, Pennsylvania., Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania., DNF, CJB, and REF contributed equally to this work.

Abstract Background: Lymphedema is the abnormal accumulation of protein-rich fluid in the interstitial space. Primary lymphedema is a rare genetic condition with both autosomal dominant and autosomal recessive modes of inheritance.

Three genes, FLT4 (VEGFR3), FOXC2, and SOX18 cause varying forms of primary lymphedema. In industrialized countries, secondary lymphedema is usually associated with cancer therapy and/or trauma. Recent observations suggested that hepatocyte growth factor/high affinity hepatocyte growth factor receptor (HGF/MET) were new candidate lymphedema genes.

Methods and Results: The coding exons and flanking regions of HGF and MET were directly sequenced in 145 lymphedema probands, 59 unrelated women with secondary lymphedema following treatment for breast cancer, 21 individual patients with lymphedema and intestinal lymphangiectasia, and at least 159 unrelated ethnic matched control individuals. Mutations leading to truncation or missense changes in evolutionarily conserved residues of HGF and MET were identified. These mutations were not polymorphic in control individuals.

Conclusions:The identification of HGF/MET mutations in primary lymphedema, lymphedema/lymphangiectasia, and breast cancer-associated secondary lymphedema suggests that the HGF/MET pathway is causal or alters susceptibility for a broad range of lymphedema phenotypes. The HGF/MET pathway provides a new target for the prevention and/or treatment of lymphedema.

Mary Ann Liebert

Estimating the population burden of lymphedema

Estimating the population burden of lymphedema

Ann N Y Acad Sci. 2008 May

Rockson SG, Rivera KK.
Stanford Center for Lymphatic and Venous Disorders, Division of Cardiovascular Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305. srockson@cvmed.stanford.edu.

Lymphedema is a complex, regional edematous state that ensues when lymph transport is insufficient to maintain tissue homeostasis. The disorder is remarkably prevalent, but the population implications of lymphatic dysfunction are not well-studied. Prevalence estimates for lymphedema are relatively high, yet its prevalence is likely underestimated. The ability to estimate the burden of disease poses profound implications for current and future lymphedema patients, but the challenge to correctly surmise the incidence and prevalence of lymphedema is complex and the relevant medical literature is scanty. In the absence of the highly desired, prospectively designed and rigorously performed relevant epidemiologic studies, it is instructive to look at the existing studies of lymphedema disease burden. In the current review, the extant literature is examined in the context of the disease setting in which tissue edema is encountered. Incidence or prevalence estimates are provided or inferred, and, where feasible, the size of the subject population is also identified. It is extremely attractive to contemplate that future approaches will entail formal, prospectively designed studies to objectively quantitate incidence and prevalence statistics for individual categories, as well as for the global lymphedema population prevalence.

Annals of the New York Academy of Sciences

Complications after polymethylmethacrylate injections: report of 32 cases - lymphedema

Complications after polymethylmethacrylate injections: report of 32 cases - lymphedema

Plast Reconstr Surg. 2008 May

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.

Plastic and Reconstructive Surgery

Intravascular B-cell lymphoma with febrile inflammatory lymphedema of the lower limbs and lower back

Intravascular B-cell lymphoma with febrile inflammatory lymphedema of the lower limbs and lower back

Ann Dermatol Venereol. 2008 AprPallure V, Dandurand M, Stoebner PE, Habib F, Colonna G, Meunier L.Service de dermatologie, groupe hospitalo-universitaire Carémeau, ruedu 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 lymphedema. 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 theclinical 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 edema of the lower limbs is not sufficient to establish lymphoma. Combined rituximab and polychemotherapy comprising a CHOP regimen appears to yield the best results.

Elsevier/Science Direct

Disseminated cutaneous leishmaniasis secondary to lymphedema: Two cases

Disseminated cutaneous leishmaniasis secondary to lymphoedema: Two cases
Ann Dermatol Venereol. 2008 Feb

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.

Elsevier

Lymphedema Seminar Boca Raton Florida

Lymphedema Seminar Boca Raton Florida

For our friends in south Florida:

Living Well with Lymphedema

10 a.m. to 1 p.m. April 12

Ruth Rales Jewish Family Service will host the event at the Jerusalem Room of the Jewish Community Center 9801 Donna Klein Blvd. Boca Raton, FL.

Seminar will feature Dr. Harvey Mayrovitz, professor, and Susan Lanham, a physical therapist at Boca Raton Community Hospital.

Call (561) 852-3330 to register.

For more information, visit Ruth Rales Jewish Family Service Center

One-sided limb lymphedema in a liver transplant recipient receiving sirolimus

One-sided limb lymphedema in a liver transplant recipient receiving sirolimus
Acta Gastroenterol Belg. 2007 Oct-Dec
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]

For further information, please see:

Lymphedema From Sirolimus Treatment

The management of genital lymphedema.

The management of genital lymphedema.

BJU Int.

2008 Mar 4

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.

Blackwell

For additional Information:

Female Genital Lymphedema

Male Genital Lymphedema

Learning from a lymphedema clinic: an algorithm for the management of localized swelling.

Learning from a lymphedema clinic: an algorithm for the management of localized swelling.

Plast Reconstr Surg. 2008 Feb

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.

Plastic and Reconstructive Surgery

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