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Burton JS, Sletten AC, Marsh E, Wood MD, Sacks JM. Adipose Tissue in Lymphedema: A Central Feature of Pathology and Target for Pharmacologic Therapy. Lymphat Res Biol 2023; 21:2-7. [PMID: 35594294 DOI: 10.1089/lrb.2022.0003] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Lymphedema is a chronic condition of impaired lymphatic flow that results in limb swelling and debilitation. The pathophysiology of lymphedema is characterized by lymphatic stasis that triggers inflammation, fibrosis, and adipose tissue deposition in the extremities. Most often, this condition occurs in cancer survivors in the years after treatment with combinations of surgery, radiation, or chemotherapy, with the major risk factor being lymph node dissection. Interestingly, obesity and body mass index are independent risk factors for development of lymphedema, suggesting interactions between adipose and lymphatic tissue biology. Currently, treatment of lymphedema involves palliative approaches, including compression garments and physical therapy, and surgical approaches, including liposuction, lymphovenous bypass, and vascularized lymph node transfer. Emerging lymphedema therapies that focus on weight loss or reducing inflammation have been tested in recent clinical trials, yielding mixed results with no effect on limb volumes or changes in bioimpedance measurements. These studies highlight the need for novel therapeutic strategies that target the driving forces of lymphedema. In this light, animal models of lymphedema demonstrate a role of adipose tissue in the progression of lymphedema and suggest these processes may be targeted in the treatment of lymphedema. Herein, we review both conventional and experimental therapies for lymphedema as well as the defining characteristics of its pathophysiology. We place emphasis on the aberrant fibroadipose tissue accumulation in lymphedema and propose a new approach to experimental treatment at the level of adipocyte metabolism.
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Affiliation(s)
- Jackson S Burton
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Arthur C Sletten
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Evan Marsh
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Matthew D Wood
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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Saneei Totmaj A, Haghighat S, Jaberzadeh S, Navaei M, Vafa S, Janani L, Emamat H, Salehi Z, Izad M, Zarrati M. The Effects of Synbiotic Supplementation on Serum Anti-Inflammatory Factors in the Survivors of Breast Cancer with Lymphedema following a Low Calorie Diet: A Randomized, Double-Blind, Clinical Trial. Nutr Cancer 2021; 74:869-881. [PMID: 34085881 DOI: 10.1080/01635581.2021.1933096] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND AIM Breast cancer-related lymphedema (BCRL) is a treatment-related inflammatory complication in breast cancer survivors (BCSs). This study was aimed to evaluate the effect of synbiotic supplementation on serum concentrations of IL-10, TGF-β, VEGF, adiponectin, and edema volume among overweight or obese BCSs with lymphedema following a low-calorie diet (LCD). METHOD In a randomized double-blind, controlled clinical trial, 88 obese and overweight BCSs women were randomized to synbiotic supplement (n = 44) or placebo (n = 44) groups and both groups followed an LCD for 10 weeks. Pre- and post-intervention comparisons were made regarding the anti-inflammatory markers which included IL-10, TGF-β, VEGF, adiponectin, edema volume, and anthropometric measurements. Also, the same factors were analyzed to find inter-group disparities. RESULTS There were no significant differences among participants in the baseline, except for IL-10 and adiponectin. Post-intervention, no significant differences were observed regarding the anti-inflammatory markers, including IL-10, VEGF, adiponectin, and TGF-β between the groups. After 10 weeks of intervention edema volume significantly decreased in the synbiotic group; additionally, anthropometric measurements (body weight, BMI, body fat percent, and WC) decreased in both groups significantly (P < 0.001 and P < 0.005; respectively). CONCLUSION Synbiotic supplementation coupled with an LCD in a 10-week intervention had beneficial effects on increasing the serum TGF-β, IL-10, and adiponectin levels in women with BCRL. It also reduced arm lymphedema volume. Therefore, synbiotic supplementation can be effective in improving health status in BCRL patients.
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Affiliation(s)
- Ali Saneei Totmaj
- Department of Nutrition, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Shahpar Haghighat
- Breast Cancer Research Center, Motamed Cancer Institute, ACECR, Tehran, Iran
| | - Shapour Jaberzadeh
- Department of Physiotherapy, School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Australia
| | - Mehraban Navaei
- Department of Nutrition, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Saeideh Vafa
- Department of Nutrition, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Leila Janani
- Department of Biostatistics, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Hadi Emamat
- Student Research Committee, Department of Clinical Nutrition and Dietetics, Faculty of Nutrition Sciences and Food Technology, National Nutrition and Food Technology Research Institute, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zahra Salehi
- Immunology Department, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Izad
- Immunology Department, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mitra Zarrati
- Department of Nutrition, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
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Abstract
Edema of the arm with associated recurrent bouts of cellulitis, occurring immediately or as late as twenty years after treatment of breast cancer, has been a very common and major complication since the initiation of surgical treat ment of breast cancer. We now know the cause and have developed methods to prevent and treat the complication.
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Affiliation(s)
- Philip G. Gallagher
- Tufts Medical School, Instructor in Surgery, Harvard Medical School, Cambridge, Massachusetts
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Omair M, Al-Azawi D, Mann GB. Sentinel node biopsy in breast cancer revisited. Surgeon 2014; 12:158-65. [PMID: 24548701 DOI: 10.1016/j.surge.2013.12.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Revised: 11/23/2013] [Accepted: 12/23/2013] [Indexed: 01/17/2023]
Abstract
The axilla has long been a focus of clinicians' attention in the management of breast cancer. The approach to the axilla has undergone dramatic changes over the last century, from radical and extended radical excisions, through the introduction of sentinel node biopsy for node negative patients to the current situation where selective management of those with nodal involvement is being introduced. The introduction of lymphatic mapping and sentinel node biopsy in the 1990's has been key to the major changes that have occurred. In less than 20 years it has moved from a hypothesis to a situation where it is the default approach to almost all clinically node negative patients and is being considered in other situations where axillary clearance was previously considered standard. This article reviews the development and introduction of sentinel node biopsy, its current uncertainties and limitations, and possible future developments.
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Affiliation(s)
- Mohammad Omair
- Department of Surgery, Royal Melbourne Hospital, University of Melbourne, Australia
| | - Dhafir Al-Azawi
- The Breast Service, Royal Melbourne and Royal Women's Hospital, Melbourne, Australia; St James's Hospital, Trinity College, Dublin, Ireland
| | - Gregory Bruce Mann
- Department of Surgery, Royal Melbourne Hospital, University of Melbourne, Australia; The Breast Service, Royal Melbourne and Royal Women's Hospital, Melbourne, Australia.
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Morcos B, Ahmad FA, Anabtawi I, Sba’ AMA, Shabani H, Yaseen R. Development of breast cancer-related lymphedema: is it dependent on the patient, the tumor or the treating physicians? Surg Today 2013; 44:100-6. [DOI: 10.1007/s00595-013-0494-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Accepted: 10/26/2012] [Indexed: 11/29/2022]
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Tsai RJ, Dennis LK, Lynch CF, Snetselaar LG, Zamba GKD, Scott-Conner C. The Risk of Developing Arm Lymphedema Among Breast Cancer Survivors: A Meta-Analysis of Treatment Factors. Ann Surg Oncol 2009; 16:1959-72. [PMID: 19365624 DOI: 10.1245/s10434-009-0452-2] [Citation(s) in RCA: 238] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2008] [Revised: 03/13/2009] [Accepted: 03/14/2009] [Indexed: 11/18/2022]
Affiliation(s)
- Rebecca J Tsai
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA, USA.
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Shaw C, Mortimer P, Judd PA. Randomized controlled trial comparing a low-fat diet with a weight-reduction diet in breast cancer-related lymphedema. Cancer 2007; 109:1949-56. [PMID: 17393377 DOI: 10.1002/cncr.22638] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Obesity is considered a risk factor for lymphedema of the arm resulting from breast cancer treatment (BCRL) as well as a poor prognostic factor in response to lymphedema treatment. The aim of the study was to compare the effect of 2 dietary interventions on excess arm volume in BCRL. METHODS A total of 64 women with BCRL were randomized to 1 of 3 groups for 24 weeks: 1) weight reduction through reduced energy intake; 2) low-fat diet with no change in energy intake (isoenergetic); 3) control group with no dietary change from habitual intake. RESULTS The primary outcome measure was arm volume at 24 weeks. Results showed significant reductions in body weight (P = .006), body mass index (P = .008), and skinfold thickness measured at 4 sites (P = .044) in the weight-reduction and low-fat groups compared with controls. A slightly greater, but not significant (P = .605), fall in excess arm volume occurred in the dietary groups but a significant correlation between weight loss (irrespective of group) and a reduction in excess arm volume (r: 0.423; P = .002) was demonstrated. CONCLUSIONS Weight loss, whether through reduced energy intake or low-fat diet, appears to be helpful in the treatment of breast cancer-related lymphedema.
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Affiliation(s)
- Clare Shaw
- Royal Marsden NHS Foundation Trust, London, UK.
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Pain SJ, Vowler S, Purushotham AD. Axillary vein abnormalities contribute to development of lymphoedema after surgery for breast cancer. Br J Surg 2005; 92:311-5. [PMID: 15672436 DOI: 10.1002/bjs.4835] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Abstract
Background
The aetiology of breast cancer-related lymphoedema (BCRL) is poorly understood and multifactorial. Previous work has suggested that acquired abnormalities of the axillary vein may contribute to arm swelling. This prospective study evaluated venous changes in patients with a new diagnosis of breast cancer who had surgery that included axillary lymph node clearance.
Methods
Patients underwent arm volume measurement and Doppler ultrasonographic assessment of the axillary vein before, and at 3 and 12 months after surgery.
Results
A complete data set was available for 70 patients. BCRL was observed in 16 per cent at 3 months and 11 per cent at 12 months. Significant alterations to venous flow patterns were observed in those with BCRL. Vein wall movement was significantly reduced after surgery for the group as a whole, but did not correlate with arm swelling. Venous stenosis with impaired flow was also observed in the absence of BCRL.
Conclusion
Axillary clearance can cause altered flow within the axillary vein, which is associated with an increased risk of developing lymphoedema.
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Affiliation(s)
- S J Pain
- Cambridge Breast Unit, Addenbrooke's Hospital, Hills Road, Cambridge CB2 2QQ, UK
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Szuba A, Razavi M, Rockson SG. Diagnosis and treatment of concomitant venous obstruction in patients with secondary lymphedema. J Vasc Interv Radiol 2002; 13:799-803. [PMID: 12171983 DOI: 10.1016/s1051-0443(07)61988-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
PURPOSE It has been proposed that concomitant iatrogenic venous obstruction substantially contributes to the appearance and severity of the secondary lymphedema that follows cancer surgery, radiation, and other traumas. The purpose of this study was to investigate the frequency of venous obstruction in the clinical presentation of patients with secondary lymphedema and to analyze the efficacy of interventional therapy in this patient population. MATERIALS AND METHODS The experience of the university center for lymphatic and venous disorders with combined lymphaticovenous edema was retrospectively examined. The records and clinical course were reviewed for all patients referred to a university lymphedema center for evaluation between January 1996 and March 1999. During this interval, in 365 patients with lymphedema, 35 radiocontrast venograms were obtained to evaluate the suspected presence of mixed lymphaticovenous edema. Venographic evidence of venous stenosis (>50%) or occlusion was analyzed, as were the technical success of the intervention, determined by ability to cross the affected segment of the vein and perform venoplasty and place the stent, and the clinical success of the intervention assessed by relief of clinical symptoms (edema, pain) within 24 hours. RESULTS The diagnosis of venous obstruction was confirmed in 17 patients (4.6% of all patients with lymphedema; 49% of patients studied with venography). Venography disclosed clinically relevant venous stenosis in five of seven patients with edema of the upper extremity and in six of 10 patients with leg lymphedema. Venous occlusion was found in two of seven patients with upper extremity edema and in four of 10 patients with leg lymphedema. Percutaneous endovascular venoplasty was attempted in all 17 patients and was successful in 16. Subsequent venous stent placement was performed in three patients with upper extremity edema and in all patients with lower extremity lymphedema. Clinical amelioration of edema was observed in 15 of these 17 patients. Amelioration was assessed by relief of symptoms, improvement in function, and reduction in limb girth. CONCLUSIONS This study supports the clinical importance of concomitant venous obstruction in some patients with chronic secondary lymphedema. Edema can often be ameliorated through percutaneous catheter-based interventions.
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Affiliation(s)
- Andrzej Szuba
- Division of Cardiovascular Medicine, Division of Interventional Radiology, Stanford University School of Medicine, Stanford, California 94305, USA
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Abstract
BACKGROUND Lymphoedema is a common complication of breast cancer treatment, affecting approximately a quarter of patients. Those affected can have an uncomfortable, unsightly and sometimes functionally impaired limb prone to episodes of superficial infection. The aetiology, pathophysiology and management of these patients is poorly understood. METHODS This is a systematic review of all published literature on lymphoedema following treatment for breast cancer, using the Medline and Cinahl databases with cross-referencing of major articles on the subject up to the end of 1999. RESULTS AND CONCLUSION The aetiology and pathophysiology of lymphoedema in patients with breast cancer appear to be multifactorial and are still not fully understood. Although conservative treatment techniques can be very successful in controlling symptoms, they do not afford a cure. The place of surgical and pharmacological therapy remains unclear. Improved understanding of the pathophysiology may assist in reducing the incidence of this condition, or help to identify those at greatest risk, in whom early initiation of conservative treatment measures may prove effective.
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Affiliation(s)
- S J Pain
- Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge, UK
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Abstract
The authors review the current understanding of lymphatic anatomy and physiology, and the pathophysiology of lymphedema. The skin lymphatic system consists of the initial lymphatics, which converge into lymphatic precollectors, collectors and lymphatic ducts; these in turn convey the lymph to the regional lymph nodes. Interstitial fluid and particles enter the initial lymphatics through interendothelial openings and by vesicular transport. Lymphatic uptake is enhanced by external compression. Lymphatic transport depends greatly on contraction of lymphangions, which generate the suction force that promotes absorption of interstitial fluid and expels lymph to collecting ducts. In lymphedema, various types of congenital and acquired abnormalities of lymphatic vessels and lymph nodes have been observed. These often lead to lymphatic hypertension, valvular insufficiency and lymphostasis. Accumulation of interstitial and lymphatic fluid within the skin and subcutaneous tissue stimulates fibroblasts, keratinocytes and adipocytes eventuating in the deposition of collagen and glycosaminoglycans within the skin and subcutaneous tissue together with skin hypertrophy and destruction of elastic fibers.
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Affiliation(s)
- A Szuba
- Division of Cardiovascular Medicine, Stanford University School of Medicine, CA 94305, USA
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Svensson WE, Mortimer PS, Tohno E, Cosgrove DO. Colour Doppler demonstrates venous flow abnormalities in breast cancer patients with chronic arm swelling. Eur J Cancer 1994; 30A:657-60. [PMID: 8080682 DOI: 10.1016/0959-8049(94)90539-8] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Chronic arm oedema following breast cancer treatment is traditionally attributed to lymphatic obstruction, with venous obstruction as an infrequent complicating factor. The axillo-subclavian venous systems of 81 patients with arm swelling following breast cancer treatment were examined with colour Doppler, duplex Doppler and grey scale ultrasound. Over half (57%) had evidence of venous outflow obstruction and a further 14% had signs of venous "congestion". Only 30% of the swollen arms had normal venous outflow. The venous systems of the contralateral non-swollen arms were all normal as were both arms in 28 control patients who had similar treatment but had not developed arm swelling. These findings suggest that venous outflow obstruction is an important contributory factor in the pathophysiology of arm swelling following breast cancer treatment.
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Affiliation(s)
- W E Svensson
- X-Ray Department, Ealing Hospital, Southall, Middlesex, U.K
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Ellis H, Colborn GL, Skandalakis JE. Surgical embryology and anatomy of the breast and its related anatomic structures. Surg Clin North Am 1993; 73:611-32. [PMID: 8378813 DOI: 10.1016/s0039-6109(16)46077-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
This article describes the embryology of the breast, its histologic appearances during the various phases of life, the gross anatomy of the breast, and its associated anatomic entities. The anatomy of the male breast also is reviewed. The surgical significance of each of these aspects is considered.
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Affiliation(s)
- H Ellis
- University of Cambridge, United Kingdom
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Kissin MW, Querci della Rovere G, Easton D, Westbury G. Risk of lymphoedema following the treatment of breast cancer. Br J Surg 1986; 73:580-4. [PMID: 3730795 DOI: 10.1002/bjs.1800730723] [Citation(s) in RCA: 533] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The incidence of lymphoedema was studied in 200 patients following a variety of treatments for operable breast cancer. Lymphoedema was assessed in two ways: subjective (patient plus observer impression) and objective (physical measurement). Arm volume measurement 15 cm above the lateral epicondyle was the most accurate method of assessing differences in size of the operated and normal arm. Arm circumference measurements were inaccurate. Subjective lymphoedema was present in 14 per cent whereas objective lymphoedema (a difference in limb volume greater than 200 ml) was present in 25.5 per cent. Independent risk factors contributing towards the development of subjective late lymphoedema were the extent of axillary surgery (P less than 0.05), axillary radiotherapy (P less than 0.001) and pathological nodal status (P less than 0.10). The risk of developing late lymphoedema was unrelated to age, menopausal status, handedness, early lymphoedema, surgical and radiotherapeutic complications, total dose of radiation, time interval since presentation, drug therapy, surgery to the breast, radiotherapy to the breast and tumour T stage. The incidence of subjective late lymphoedema was similar after axillary radiotherapy alone (8.3 per cent), axillary sampling plus radiotherapy (9.1 per cent) and axillary clearance alone (7.4 per cent). The incidence after axillary clearance plus radiotherapy was significantly greater (38.3 per cent, P less than 0.001). Axillary radiotherapy should be avoided in patients who have had a total axillary clearance.
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Halasz NA. Operative considerations in radical mastectomy. Am J Surg 1967; 114:862-6. [PMID: 4862847 DOI: 10.1016/0002-9610(67)90407-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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CUTHBERTSON AM. Management of Lymphoedema of the Arm following Treatment for Carcinoma of the Breast. AUSTRALASIAN RADIOLOGY 1963; 7:117-9. [PMID: 14024393 DOI: 10.1111/j.1440-1673.1963.tb03418.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Schorr S, Hochmann A, Fraenkel M. Phlebographic study of the swollen arm following radical mastectomy. ACTA ACUST UNITED AC 1954; 6:104-8. [DOI: 10.1016/s0368-2242(54)80061-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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ROBINSON EK. Results in treatment of cancer of the breast. J Am Geriatr Soc 1953; 1:642-7. [PMID: 13096263 DOI: 10.1111/j.1532-5415.1953.tb03948.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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URBAN JA, BAKER HW. Radical mastectomy in continuity with en bloc resection of the internal mammary lymph-node chain; a new procedure for primary operable cancer of the breast. Cancer 1952; 5:992-1008. [PMID: 12988188 DOI: 10.1002/1097-0142(195209)5:5<992::aid-cncr2820050515>3.0.co;2-z] [Citation(s) in RCA: 158] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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TREVES N. Prophylaxis of postmammectomy lymphedema by the use of gelfoam laminated rolls.A preliminary report, with a review of the theories on the etiology of elephantiasis chirurgica and a summary of previous operations for its control. Cancer 1952; 5:73-84. [PMID: 14886900 DOI: 10.1002/1097-0142(195201)5:1<73::aid-cncr2820050110>3.0.co;2-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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