Observations on the Swollen Arm After Radical Mastectomy†

Low-level laser therapy in management of postmastectomy lymphedema

The aim of this paper was to study the effects of low-level laser therapy (LLLT) in the treatment of postmastectomy lymphedema. Eleven women with unilateral postmastectomy lymphedema were enrolled in a double-blind controlled trial. Patients were randomly assigned to laser and sham groups and received laser or placebo irradiation (Ga-As laser device with a wavelength of 890 nm and fluence of 1.5 J/cm2) over the arm and axillary areas. Changes in patients' limb circumference, pain score, range of motion, heaviness of the affected limb, and desire to continue the treatment were measured before the treatment and at follow-up sessions (weeks 3, 9, 12, 18, and 22) and were compared to pretreatment values. Results showed that of the 11 enrolled patients, eight completed the treatment sessions. Reduction in limb circumference was detected in both groups, although it was more pronounced in the laser group up to the end of 22nd week. Desire to continue treatment at each session and baseline score in the laser group was greater than in the sham group in all sessions. Pain reduction in the laser group was more than in the sham group except for the weeks 3 and 9. No substantial differences were seen in other two parameters between the two treatment groups. In conclusion, despite our encouraging results, further studies of the effects of LLLT in management of postmastectomy lymphedema should be undertaken to determine the optimal physiological and physical parameters to obtain the most effective clinical response.

Axillary vein abnormalities contribute to development of lymphoedema after surgery for breast cancer

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.

The reliability of a simplified water displacement instrument: A method for measuring arm volume

OBJECTIVES

To present a new water displacement measurement, the Simplified Water Displacement Instrument (SWDI), and to evaluate its intra- and intertester reliability.

DESIGN

Reliability design.

SETTING

Hospital setting.

PARTICIPANTS

Fifty-six healthy people were studied. Intratester reliability was evaluated once a week for 4 weeks in 20 women and 10 men. Intertester reliability was assessed by 2 physical therapists in 26 people.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Coefficients of variation (CVs) and intraclass correlation coefficients (ICCs).

RESULTS

The intratester reliability showed a CV range of 2.2% to 2.6% and an ICC range of .98 to .99. The intertester reliability showed a CV of 1.3% and an ICC of .99. There was a significant increase in arm volume in men compared with women. There were no significant differences in changes in volume over the 4 weeks. There was a significant greater right arm volume (3.3%) among the right-handed subjects (P<.001).

CONCLUSIONS

Both intra- and intertester reliability were satisfactory for the SWDI.

The Addition of Manual Lymph Drainage to Compression Therapy For Breast Cancer Related Lymphedema: a Randomized Controlled Trial

PURPOSE

The purpose of this investigation was to compare the reduction in arm lymphedema volume achieved from manual lymph drainage massage (MLD) in combination with multi-layered compression bandaging (CB) to that achieved by CB alone.

METHODS AND MATERIALS

Fifty women with lymphedema (mean age of 59 years +/- 13 years) were randomly assigned to 4 weeks of combined MLD/CB or CB alone. The primary study endpoint was the reduction in arm lymphedema volume, which was determined by water displacement volumetry and measurement of circumference. Independent assessors, blinded to subject treatment assignment, performed the outcome measurements.

RESULTS

Arm lymphedema volume decreased significantly after 4 weeks irrespective of treatment assignment (p < 0.001). Individuals with mild lymphedema receiving combined MLD/CB had a significantly larger percentage reduction in volume compared to individuals with mild lymphedema receiving CB alone, and compared to individuals with moderate or severe lymphedema receiving either treatment.

CONCLUSION

These findings indicate that CB, with or without MLD, is an effective intervention in reducing arm lymphedema volume. The findings suggest that CB on its own should be considered as a primary treatment option in reducing arm lymphedema volume. There may be an additional benefit from the application of MLD for women with mild lymphedema; however, this finding will need to be further examined in the research setting.

Lymphedema Secondary to Postmastectomy Radiation: Incidence and Risk Factors

BACKGROUND

Postmastectomy radiotherapy (PMRT) has proven benefits for certain patients with breast cancer; however, one of its complications is lymphedema. This study examines the incidence of and risk factors associated with lymphedema secondary to PMRT.

METHODS

The charts of patients treated with mastectomy at Roswell Park Cancer Institute between January 1, 1995, and April 20, 2001, who received PMRT were reviewed. Univariate analysis of patient, disease, and treatment variables was conducted. Multivariate analysis was performed on variables found to be significant in univariate analysis.

RESULTS

One hundred five patients received PMRT. The incidence of lymphedema was 27%. Patient age, body mass index, disease stage, positive lymph nodes, nodes resected, postoperative infection, duration of drainage, chemotherapy, and hormonal therapy were not associated with lymphedema. Total dose (P =.032), posterior axillary boost (P =.047), overlap technique (P =.037), radiotherapy before 1999 (P =.028), and radiotherapy at Roswell Park Cancer Institute (P =.028) were significantly associated with lymphedema. Increased lymphedema was noted with supraclavicular, internal mammary, mastectomy scar boost, and chest wall tangential photon beam radiation, but the associations were not statistically significant.

CONCLUSIONS

The high incidence and debilitating effects of lymphedema must be weighed against the benefits of PMRT. Efforts to prevent lymphedema should be emphasized.

Lymphoedema following surgery for breast cancer

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.

Lymphedema in women treated for breast cancer

OBJECTIVES

To review the clinical and evidence-based knowledge of lymphedema in women treated for breast cancer, including the anatomy, physiology, pathophysiology, diagnosis, management, and nursing role.

DATA SOURCES

Research studies, review articles, clinical literature, American Cancer Society lymphedema work group proceedings.

CONCLUSIONS

Arm lymphedema can be a consequence of treatment for breast cancer and may affect all aspects of quality of life at any time during recovery and long-term survivorship. Prevention and early treatment are vital.

IMPLICATIONS FOR NURSING PRACTICE

As patient advocates, nurses can document patient complaints, conduct arm assessments, and reinforce arm precautions at every clinical visit. Knowledge of research and treatment advances is crucial to enhancing the quality of life of women treated for breast cancer.

Prevalence and aetiology of lymphoedema after breast cancer treatment in southern Tasmania

BACKGROUND

Lymphoedema can be a devastating complication of surgical treatment for breast cancer. There is a lack of research on its prevalence in Australia which has hindered the development of measures to combat the condition. The aims of this study were to establish the prevalence and investigate the aetiology of upper limb lymphoedema in women treated for breast cancer in the years 1994-1996 in southern Tasmania.

METHODS

A standard volumetric water displacement technique was used to measure the arms of 201 women. A subjective assessment of swelling was also made by each patient. Factors analysed for statistical association with lymphoedema were: patient characteristics, type of treatment and tumour, and lymph node pathology.

RESULTS

The overall objective prevalence rate, regardless of treatment type, was 11%; whereas, the subjective rate was 23.4%. The objective prevalence for procedures involving axillary surgery was 14.2%. Significant statistical associations were found between arm size and body mass index at time of assessment (r = 0.15, P = 0.04); type of surgery (Chi-squared test = 11.06, P = 0.05); surgery to axilla (U = 2515.5, P = 0.002); tumour size (r = 0.17, P = 0.03); and tumour grade (Chi-squared test = 6.5 1, P = 0.04). No significant relationship was found between lymphoedema and axillary irradiation, number of lymph nodes removed, age or handedness of the patient.

CONCLUSIONS

Women receiving axillary dissection as part of their breast cancer treatment carry a significant risk of developing lymphoedema, regardless of the extent of surgery. The causative role of axillary irradiation was not supported. Future research should concentrate on less invasive alternatives to axillary dissection, such as sentinal lymph node biopsy.

Edema volume, not timing, is the key to success in lymphedema treatment

BACKGROUND

There are currently between 1 and 2 million breast cancer survivors in the United States. Is the advocated, early intervention the key to successful treatment, or are there other, more important factors?

METHODS

Responses to combined decongestive therapy (CDT) for 69 women were analyzed with regard to duration of lymphedema, differences in arm circumference, percent differences in arm volumes, volume of edema, reduction of edema volumes, and duration of treatment.

RESULTS

Two- and three-dimensional (2D and 3D) analyses showed little correlation between duration and volume of edema or between duration and response and treatment. However, they did show a correlation between initial volumes of fluid in the tissues and responses. Patients with initial volumes of 250 mL or less had a mean reduction of 78% with CDT, whereas those with initial volumes between 250 and 500 mL had a mean reduction of 56%.

CONCLUSION

The key to predicting successful lymphedema treatment is the initial volume of edema in the tissues regardless of whether the intervention is early or late.

POST-MASTECTOMY SWELLING OF THE ARM: REVIEW OF THE LITERATURE AND PRELIMINARY REPORT OF 50 CASES

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Focused review: postmastectomy lymphedema

Upper extremity lymphedema is a relatively frequent complication following the management of breast cancer. This focused review of the pathophysiology, complications, and various treatment options now available for its management will allow physiatrists and other practitioners to better understand this condition and thereby serve as a resource for patients and other physicians.

Incidence of arm swelling following axillary clearance for breast cancer

Arm swelling was measured using volume determination in 118 patients following mastectomy (n = 60) or wide excision (n = 58), both with axillary clearance. The mean age was 60.5 years and the median follow-up was 22.5 months. Axillary clearance removed level III nodes. Axillary irradiation was given to only three patients with extensive (more than 75 per cent) nodal involvement. The incidence of early postoperative complications was 18.6 per cent. The incidence of lymphoedema was 7.6 per cent (nine patients). Three of these patients had early lymphoedema within 6 months of treatment. Arm circumference differences correlated poorly with volume differences. The incidence of lymphoedema following axillary clearance is low and comparable to that for sampling or no axillary surgery.

Factors that influence the incidence of brachial oedema after treatment of breast cancer

Six factors that may increase the likelihood of swelling of the arm after treatment of breast cancer were investigated in 136 patients who had undergone treatment. The highest incidence of oedema was among patients who had received radiotherapy in high doses with few fractions to the axilla (60%), and in patients with a history of one or more infections in the arm on the operated side (89%). Overweight, oblique surgical incision, infection in the arm, and radiotherapy correlated with arm swelling. The age of the patient and whether the operation had been done on the dominant or non-dominant side correlated less with the incidence of oedema.

Decompression of the axillary vein for oedema of the arm caused by axillary dissection and irradiation

Twenty women with brachial oedema after treatment for breast cancer were operated on by a standard technique, with decompression of the axillary vein and division of the irradiated portion of pectoralis major. After a mean follow-up of 32.5 months a significant improvement was noted in 14 of them. In 19 the range of movement of the shoulder had improved.

Importance of time in assessing arm and hand function after treatment of breast cancer

Ninety-three patients were examined on two occasions at 24-month intervals after surgery and irradiation for breast cancer. Stiffness of the shoulder joint, brachial oedema, pain in the arm, and the patients' subjective assessment of the degree of functional disability were registered. The results indicated that both oedema and stiffness of the shoulder joint are acceptable measures of functional impairment. We conclude, however, that such measurements should not be used as indicators of prognosis, because spontaneous improvement can occur for two years or more after treatment.