LYMPHEDEMA AND BREAST CANCER
the developed world the number one cause of secondary lymphedema is the
of lymph nodes for cancer biopsies, especially breast cancer.
It is also one of the most preventable types of lymphedema. With the advent of PET/CAT scans, ultra-sounds, MRI's in addition to ultra-sound guided small needle biopsies, doctor should seriously consider the ramifications of whole node removal.
What makes arm lymphedema even more frustrating is that patients are almost never told of the possibility of lymphedema and/ or if occurs is often labled as temporary. For the few who are actually told it is lymphedema, their physicians will tell them there is nothing yhou can do about it.
To me, this lack of education about lymphedema and the seemingly indifferent attitudes of the medical world towards it is nothing but poor medicine if not outright neglect or malpractice.
II feel each patient needs to be referred to a lymphedema therapist BEFORE biopsies are done and/or before any treatment occurs. That way, at least they won't go through the terrible shock, discouragement and anger they presently experience.
Symptoms and Early Signs of breast cancer related arm lymphedema include:
Swelling in the arms, hands, fingers, shoulders, chest, or legs. The swelling may occur for the first time after a traumatic event (such as bruises, cuts, sunburn, and sports injuries), after an infection in the part of the body that was treated for cancer, or after an airplane trip lasting more than three hours.
A "full" or heavy sensation in the arms or legs.
Decreased flexibility in the hand, wrist, or ankle.
Difficulty fitting into clothing in one specific area.
Tight-fitting bracelet, watch, or ring that wasn't tight before.
Stiffness, weakness, or numbness
Tingling - some patients report a tingling sensation when LE begins. It is often described as a "needles and pin" sensation.Pain or aching in the arm
Arm Swelling After Breast Cancer
Permanent Leg or Arm Swelling
****In the situation of any permanent leg swelling whether the cause is known or unknown, the diagnoses of lymphedema must be considered****
There are several groups of people who experience leg or arm swelling from known causes, but if it doesn't go away or unknown causes where the swelling can actually get worse as time goes by.
This group includes those who have had the injuries, infections, insect bites, trauma to the leg, surgeries or reaction to a medication. When this swelling does not go away, and becomes permanent it is called secondary lymphedema.
Another extremely large group that experiences permanent leg or arm swelling are cancer patients, people who are morbidly obese, or those with the condition called lepedema. What causes the swelling to remain permanent is that the lymph system has been so damaged that it can no longer operate normally in removing the body's waste fluid.
In cancer patients this is the result of either removal of the lymph nodes for cancer biopsy, radiation damage to the lymph system, or damage from tumor/cancer surgeries.
This is also referred to as secondary lymphedema.
Group three consists of people who have leg or arm swelling from seemingly unknown reasons. There may be no injury, no cancer, no trauma, but for some reason the leg simply is swollen all the time.
The swelling may start at birth, it may begin at puberty, or may begin in the 3rd, 4th or even 5th decade of life or sometimes later.
This type of leg or arm swelling is called primary lymphedema. It can be caused by a genetic defect, malformation or damage to the lymph system while in the womb or at birth or be part of another birth condition that also effects the lymph system.
This is an extremely serious medical condition that must be diagnosed early, and treated quickly so as to avoid painful, debilitating and even life threatening complications. Treatment should NOT include the use of diuretics.
What is Lymphedema?
Lymphedema is defined simply as an accumulation of excessive protein rich fluid in the tissues of the leg. The accumulation of fluid causes the permanent swelling caused by a defective lymph system.
A conservative estimate is that there may be 1-2 million people in the United States with some form of primary lymphedema and two to three million with secondary lymphedema.
What are the symptoms of Lymphedema?
If you are an at risk person for arm lymphedema there are early warning signs you should be aware of. If you experience any or several of these symptoms, you should immediately make your physician aware of them.
1.) Unexplained aching, hurting or pain in the arm
2.) Experiencing "fleeting lymphedema." This is where the limb may swell, even slightly, then return to normal. This may be a precursor to full blown arm lymphedema.
3.) Localized swelling of any area. Sometimes lymphedema may start as swelling in one area, for example the hand, or between the elbow and hand. This is an indication of early lymphatic malfunction.
4.) Any arm inflammation, redness or infection.
5.) You may experience a feeling of tightness, heaviness or weakness of the arm.
How is Lymphedema Treated?
The preferred treatment today is decongestive therapy. The forms of therapy are complete decongestive therapy (CDT) or manual decongestive therapy (MDT), there are variances, but most involve these two type of treatment.
It is a form of massage therapy where the leg is very gently massaged to actually move the fluid out of the leg and into an area where the lymph system still functions normally.
With these massage treatments, swelling is reduced and then the patient is fitted with a pre-measured custom pressure garment to keep the swelling down and/or is taught to use compression wraps to maintain the leg size.
What are some of the complications of lymphedema?
Infections such as cellulitis,
lymphangitis, erysipelas. This is due not only to the large
fluid, but it is well documented that lymphodemous limbs are localized
2. Draining wounds that leak lymphorrea which is very caustic to surrounding skin tissue and acts as a port of entry for infections.
3. Increased pain as a result of the compression of nerves usually caused by the development of fibrosis and increased build up of fluids.
4. Loss of Function due to the swelling and limb changes.
5. Depression - Psychological coping as a result of the disfigurement and debilitating effect of lymphedema.
6. Deep venous thrombosis again as a result of the pressure of the swelling and fibrosis against the vascular system. Also, can happen as a result of cellulitis, lymphangitis and infections.
7. Sepsis, Gangrene are possibilities as a result of the infections.
8. Possible amputation of the limb.
9. Pleural effusions may result if the lymphatics in the abdomen or chest are to overwhelmed to clear the lung cavity of fluids.
10. Skin complications such as splitting, plaques, susceptibility to fungus and bacterial infections.
11. Chronic localized inflammations.
Can lymphedema be cured?
No, at the present time there is no cure for lymphedema. But it can be treated and managed and most of the complications can be avoided. Life with lymphedema can still be active and full, with proper treatment, patient education, and patient life style adaptation.
For extensive information on lymphedema, please visit our home page:
(c) Copyright 2005 by Pat O'Connor and Lymphedema People. Use of this information for educational purpose is encouraged and permitted. It must be available free and without charge and not used for financial renumeration or gain. Please include an acknowledgement to the author and a link to Lymphedema People.
BREAST CANCER SURVIVORS NOT TOLD ABOUT LYMPHEDEMA SIDE-EFFECT
COLUMBIA, Mo. – According to the American Cancer Society, nearly 200,000 women in the United States will develop breast cancer this year. However, few people realize that half of those women will develop lymphedema, a condition in which significant, persistent and painful swelling occurs, most often in the arm. A team of University of Missouri-Columbia researchers has discovered that women with lymphedema not only experience a much broader array of physical and psychological difficulties than previously reported but were rarely informed by their doctors of the possibility of developing the condition.
“One of the most surprising and significant stressors indicated by almost all the women was the perceived lack of care and concern from many of the health-care providers, particularly the medical doctors,” said Puncky Heppner, project leader and chair of MU’s department of educational, school and counseling psychology. “Many indicated they were not informed of lymphedema at any time during their medical care for breast cancer, which is alarming because this condition predisposes the women to infection, which can easily become life-threatening.”
Heppner and his team conducted interviews with Midwestern, Caucasian women, ranging in age from 47 to 87, with breast cancer and lymphedema. Due to lymphedema, some women had difficulty sleeping, carrying items, exercising, including walking, and fitting comfortably into clothes.
Heppner noted that lymphedema had a psychological impact as well. Women experienced a complete loss of interest in dress and appearance, sexual and interpersonal relations, occupational aspirations and self-esteem.
“This neglect of lymphedema by health care providers has not only meant that women go undiagnosed and fail to receive basic preventive information but also has inhibited the development of effective psychosocial interventions,” Heppner said.
When women were aware they had lymphedema, Heppner found, they actively sought information or treatment options and developed and learned physical strategies to manage the condition. They tried to accept their limitations brought on by lymphedema and focused on the positive aspects of their lives in order to cope with their distress.
WHAT IS IT?
Lymphedema is a buildup of a fluid called lymph and protein in the tissues under the skin. Lymph accumulates when there is an obstruction to normal flow causing swelling, usually in an arm or leg. The lymph system is similar to the blood system in its network of vessels that carry lymph fluid throughout the body.
Trauma to lymphatic tissue by surgery or radiotherapy is the main cause of lymphedema in the context of cancer. It can result from surgery and/or radiation therapy during treatment for cancers of the breast, abdomen, melanoma, connective tissues (sarcomas) and the pelvic area, as well as lymphomas, in both men and women. Lymphedema may also be the result of infection, such as dermatophytosis in the foot.
Cancer tumors also can block the lymph vessels, especially in people with prostate cancer or lymphoma.
IF I HAVE CANCER WILL I DEVELOP LYMPHEDEMA?
Not necessarily. The most frequent cases occur in women with breast cancer; 10% to 25% of breast cancer patients will develop lymphedema. While most cases are mild, approximately 400,000 women cope daily with some degree of disfigurement, discomfort, and sometimes disability because of arm and hand swelling.
Because of improvements in radiation and surgical techniques (such as removing smaller samples of lymph nodes), lymphedema is less common today than it use to be. Lymphedema develops in about one in four breast cancer patients who have a mastectomy with lymph-node dissection. The risk doubles for those who also receive radiation treatments to the underarm area.
Radical prostatectomy, a procedure that removes the prostate gland, seminal vesicles and sometimes the nearby pelvic lymph nodes, can lead to lymphedema .One type of Kaposi’s sarcoma is called the lymphadenopathic form that can spread throughout the body and may aggressively involve lymph nodes, viscera, and occasionally the GI tract – resulting in a kind of lymphedema.
SENTINEL LYMPH NODE BIOPSY
IIf breast cancer spreads, it first goes to the lymph nodes under the arm. That's why women with breast cancer have these nodes examined. Until recently, surgeons would remove as many lymph nodes as possible, but this greatly increased the risk of lymphedema. More recently, a growing number of physicians have begun focusing on finding the sentinel nodes — the first nodes to receive the drainage from breast tumors and therefore the first to show evidence of cancer’s spread. Experts believe that if a sentinel node is removed and found to be healthy, then the chance of finding cancer in any of the remaining nodes is very small and no other nodes need to be removed. This spares as many as 75% of women who have no evidence of tumor spread to the axillary nodes the risk of complications, especially lymphedema.
WHEN DOES IT DEVELOP?
Lymphedema can appear any time after surgery or radiation treatment including many years later.
When the condition develops very soon after surgery, it is usually mild, and goes away within one to two weeks. It can also develop six to eight weeks after surgery or radiation. Again, this type of lymphedema usually goes away in a few weeks.
Unfortunately, the more common form of lymphedema in cancer survivors develops slowly over time. It may show up many months or even years after treatment ends and swelling can range from mild to severe. In most cases however, lymphedema appears between six and 12 months after treatment. While people who have many lymph nodes removed and radiation therapy have the highest risk of developing lymphedema, some high-risk patients won’t develop the condition.
WHEN TO CALL A PROFESSIONAL
Patients should contact a physician if they had a mastectomy, lower abdominal surgery or radiation treatments in the past, and the affected limb becomes red, painful or hot, or if it develops open sores or areas of broken skin. Doctors should be consulted especially if there is a fever in addition to swelling.
Usually, no specific testing is necessary to diagnose lymphedema, but tests may be done such as a blood count that can identify signs of infection. Ultrasound may be ordered to look for blood clots, which can cause swelling. Computed tomography (CT) may be used to find a tumor that could be blocking lymph vessels. In addition, there are more specialized tests that can identify lymph flow and lymph vessel abnormalities.
The first signs of lymphedema can be a change in a patient’s arms or legs or other affected area such as the groin. Initially, skin will remain soft, but if the problem continues, the limb may become hot and red and the skin hard and stiff. The lymph fluid that collects in the tissues can be very uncomfortable, but pain is not always present. Early symptoms of lymphedema may include:
In most cases, only one arm or leg is affected. If the leg is involved, swelling usually begins at the foot, then progresses upward toward the ankle, calf and knee.
The severity is directly related to the extent of surgery and radiation treatment to the lymph nodes. Severity and general risk of developing lymphedema seems to increase with obesity, weight gain and infection in the affected area.
Lymphedema has no cure so treatment focuses on reducing the symptoms. Treatment has varied from virtually no treatment to surgery, but there are various practical methods to deal with the condition, including elevation of the limb (in the first year only), compression garments (no greater than 20-30 mm Hg), certain types of massage and exercises, pneumatic compression devices (controversial), and other types of physical therapy. Experts also recommend keeping the affected limb clean, dry and lubricated.
The National Lymphedema Network (www. Lymphnet.org) encourages massage by an specially certified expert in lymphedema massage.. In many cases, patients can also be trained to massage themselves to improve the flow of lymph fluids.
There are no medications to treat lymphedema. Diuretics have been found to be ineffective and may actually exacerbate the condition. Other medicines have been tried, but there is no clear evidence of significant effectiveness with any particular drug.
arm or leg above the level of the
heart(during the first year) and flexing it frequently are basic
manage the condition. Since elevation is impractical except for short
patients should be fitted with an elastic sleeve, covering the arm or
A significant reduction in edema (swelling) has been reported after wearing elastic sleeves for 6 consecutive hours per day. Using these garments during exercise, physical activity, and especially air travel is recommended, since air travel seems to exacerbate the condition.
If the legs are affected, avoid periods of prolonged standing. If working or standing a lot, a doctor may prescribe special graduated compression stockings to wear throughout the day. A doctor may also suggest a protein-rich, low-salt diet for those who are over-weight or obese.
MODERATE TO SEVERE:
For people with moderate to severe lymphedema in the legs, doctors prescribe pneumatic compression devices to be used at home to help reduce limb swelling. The “pneumatic stockings” are worn every day for an hour or two to reduce the swelling. Once the swelling has been reduced, a person may still need to wear elastic stockings up to the knee every day from the moment of rising until bedtime.
For lymphedema in the arm, pneumatic sleeves--like pneumatic stockings--can be used every day to reduce the swelling; elastic sleeves may also be needed.
Others recommend a special type of massage therapy called manual lymph drainage. Antibiotics also may be prescribed to prevent or treat infection in the affected limb. Since skin infections can be more serious in people with lymphedema, a person may need to have antibiotics administered intravenously in the hospital during an infection.
Complex Decongestive Therapy
More serious cases of lymphedema can be treated with Complex Decongestive Therapy by a physical therapist or other health care professional, who has special training. Complex Decongestive Therapy consists of skin care, massage, special bandaging, exercise, and fitting for a compression sleeve. Seeking and getting treatment early should lead to a shorter course of treatment to get the lymphedema under control. While most insurance companies will pay for this treatment, some do not.
certified in the procedure should perform
Manual Lymph Drainage (MLD).
In the case of lymphedema of the arm, the procedure involves a type of massage that moves built up fluid around the blocked vessels and across the chest to the other side of the body where the lymphatic system is still in tact. Usually the healthy area will be “worked” first. After each treatment, the effected area is carefully bandaged with a special layered wrap that looks like an ace bandage but is made of a different fabric. The wrap is important for keeping the effected limb de-congested. An average course is 15 daily treatments of 60 to 90 minutes each. After a MLD course of treatments, the patients will wear a compression garment every day. The patient should be measured for a new compression sleeve every six months or so. Sometimes a yearly MLD treatment course is recommended as a kind of “tune up.”
lymphedema development may occur even
after several decades, patients should monitor themselves for signs of
lymphedema and report any changes to their physicians.
Prevention is important and can require daily attention to manage the symptoms of swelling in particular. Arm and hand precautions are based on two key ideas: (1) Do not increase lymph production, which is directly proportional to blood flow, and (2) do not increase blockage to lymph system. Therefore, patients should avoid excessive heat, infections, and overly-strenuous arm exercises which would increase blood flow in the arm and thereby increase lymph production.
Patients should follow these suggestions to manage their lymphedema:
It is important to use your affected limb for normal everyday activities, yet overuse can cause lymphedema to occur in some people. Follow these suggestions whenever possible:
For More Information
American Cancer Society
The American Cancer Society held an international conference on lymphedema in 1998 in New York City. It involved 60 of the world’s leading experts and included a forum of more than 250 breast cancer survivors, leaders of breast cancer advocacy groups, and others. The conference report plus a lymphedema resource guide are available as a book from the ACS at cancer.org. (See below for title.)
National Lymphedema Network
Lymphedema Network is a charitable
organization with an international scope. Founded in 1988, the
mission is to provide education and guidance to patients and health
professionals. The Network promotes standardizing quality treatment for
lymphedema patients. In addition, the organization supports research
causes and possible alternative treatments for this “often
*Source Link No Longer Available
Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, MI.
To determine the rates of breast cancer-related lymphedema (BCRL) in patients undergoing whole-breast irradiation as part of breast-conserving therapy (BCT) and to identify clinical, pathologic, and treatment factors associated with its development.
A total of 1,861 patients with breast cancer were treated at William Beaumont Hospital with whole-breast irradiation as part of their BCT from January 1980 to February 2006, with 1,497 patients available for analysis. Determination of BCRL was based on clinical assessment. Differences in clinical, pathologic, and treatment characteristics between patients with BCRL and those without BCRL were evaluated, and the actuarial rates of BCRL by regional irradiation technique were determined.
The actuarial rate of any BCRL was 7.4% for the entire cohort and 9.9%, 14.7%, and 8.3% for patients receiving a supraclavicular field, posterior axillary boost, and internal mammary irradiation, respectively. BCRL was more likely to develop in patients with advanced nodal status (11.4% vs. 6.3%, p = 0.001), those who had a greater number of lymph nodes removed (14 nodes) (9.5% vs. 6.0%, p = 0.01), those who had extracapsular extension (13.4% vs. 6.9%, p = 0.009), those with Grade II/III disease (10.8% vs. 2.9%, p < 0.001), and those who received adjuvant chemotherapy (10.5% vs. 6.7%, p = 0.02). Regional irradiation showed small increases in the rates of BCRL (p = not significant).
These results suggest that clinically detectable BCRL will develop after traditional BCT in up to 10% of patients. High-risk subgroups include patients with advanced nodal status, those with more nodes removed, and those who receive chemotherapy, with patients receiving regional irradiation showing a trend toward increased rates.
PMID: 15095073 [PubMed - indexed for MEDLINE]
....................................................................Effect of upper extremity exercise on secondary lymphedema in breast cancer patients: a pilot study.
PMID: 12560436 [PubMed - indexed for MEDLINE]
Overview of treatment options and review of the current role and use of compression garments, intermittent pumps, and exercise in the management of lymphedema.
Brennan MJ, Miller LT.
Bridgeport Hospital, Connecticut, USA.
BACKGROUND: Lymphedema is a relatively frequent complication following the management of breast carcinoma. Numerous therapeutic interventions have been offered to treat this potentially disabling and disfiguring condition. Consensus has not been attained among oncologists, surgeons, psychiatrists, and physical therapists concerning the appropriate treatment of lymphedema.
METHODS: This review provides an overview of those treatment regimens that have been used in the past and, in some instances, have gone on to provide the foundation for the most widely prescribed interventions currently employed for the management of upper extremity lymphedema following breast carcinoma treatment. The use of intermittent pneumatic compression pumps as a part of an integrated multidisciplinary treatment approach incorporating garments, exercises, and massage also is discussed.
RESULTS: A review of available literature suggests that a variety of traditional and commonly available techniques, when used appropriately in a multidisciplinary fashion, may lessen the cosmetic and physical impairments associated with acquired lymphedema. The role of surgery is unclear. Pharmacotherapies are a promising adjunct to manual and mechanical therapies.
CONCLUSIONS: The appropriate use of readily available
approaches may lessen the severity of acquired lymphedema following
carcinoma therapy. A comprehensive therapeutic approach should be
the management of lymphedema, including attention to the functional,
and emotional sequelae of this potentially disabling condition. To that
recommendation for a comprehensive treatment regimen is provided.
SMALL NEEDLE BIOPSY
What to expect...
What is a needle biopsy?
It is a medical test that helps identify the cause of an abnormal lump or mass in your body. This procedure is performed in the Radiology Department by a specially trained doctor called an radiologist. A small needle is inserted into the abnormal area and a sample of tissue is removed, which is then given to a pathologist to examine under a microscope. The pathologist can determine if the abnormal tissue is cancer, non-cancerous tumor, infection or scar.
What is the purpose of a needle biopsy?
Imaging tests, such as CAT scan (CT), ultrasound, magnetic resonance imaging (MRI) and mammography, can find abnormal masses, but these tests alone cannot always tell you what the lump or mass is. In order to provide you with the best care and proper treatment, your doctor needs this additional information.
What do I do to prepare for the biopsy?
In most cases, you will be an outpatient when you have the biopsy. You will come to the Outpatient Registration Center two hours before your appointment time to register, get necessary labs drawn (which some lab tests take 1-2 hours to get results), and in some instances an intravenous (IV) line will be started. You will be notified if any special diet or medication instructions are to be followed. You will return home after the procedure. Wear comfortable clothes. You may bring something to read or a headset radio with you.
If you are a patient in the hospital, your nurses and doctors will give you the correct instructions on how to prepare for your biopsy.
What is a needle biopsy like and will it hurt?
With the aid of some form of imaging (such as live x-rays, CT, ultrasound, or mammography) the interventional radiologist will determine the best site for the biopsy. The radiologist will then clean the area where the biopsy is going to be performed and put a local anesthetic into the skin and deeper tissues to numb the area. In some instances, an IV will be started so that the interventional radiologist can give you fluids and medicines during the biopsy.
The radiologist will then put a small needle into the mass or lump. The doctor will take an image of the biopsy area during the procedure to make sure the needle is in the right place. Some pressure may occur during the test. A tiny piece of tissue or some cells from the mass are obtained through the biopsy needle. The test itself usually takes around one hour.
The tissue or cell sample is sent to the laboratory and a pathologist will examine the sample under a microscope. It usually takes 2-3 days for the biopsy results.
What do I do after the biopsy?
If you are an Outpatient:
You will be taken to an outpatient recovery area to stay and be observed for 2-4 hours. As long as there are no complications, most people go home after 2-4 hours. Take things easy for the rest of the day. It is not uncommon to be sore in the biopsy area for 1-2 days.
If you are an Inpatient:
You will be observed for 2-4 hours and then resume your previous routine.
What are the risks of having a needle biopsy?
Because such a small needle is used, there are very few risks to a biopsy. Fewer than 1% of all patients develop bleeding or infection. Complications are very infrequent. The radiologist will discuss the risks in detail with you before he starts the test.
Occasionally, you may be asked to return for a second needle biopsy or a surgeon may have to do an operation to get the tissue or cell sample. About 90% of the needle biopsies provide enough information for the pathologist to determine the cause of the mass or lump.
What are the benefits of having a needle biopsy?
In the past, surgery was needed to remove tissue to be examined, but now with the aid of a needle biopsy, your health question can be answered without surgery.
*link no longer available
What is a fine needle biopsy?
Fine Needle Biopsy of the Breast is a procedure where a very small needle will be introduced into the area in question and some cells from this area will be drawn into the tip of the needle using a syringe. Slides are then prepared and sent to a pathologist. The pathologist is then able to determine whether there are any suspicious cells present.
How is it done?
Almost all fine needle biopsies are performed using ultrasound. Ultrasound is able to target the area and using the ultrasound image the needle can be directed into the correct position with great accuracy.
Will it be painful?
The procedure is performed using a small amount of local anaesthetic. The local anesthetic does sting slightly and sometimes there is some further minor discomfort as the small needle is introduced into the correct area. The pain is usually minimal and the vast majority of patients manage the procedure without any significant discomfort.
Are there any risks?
Fine needle biopsy is an extremely safe procedure. There is always a small amount of bleeding and bruising around the biopsy site. The breast at this site is often a little tender for a few days and there may be minimal bruising in the skin overlying the area. It is extremely unusual for there to be any major bruising or bleeding. It is however very important to let the radiologist know if you have any clotting disorders or are on any medication to thin the blood eg. Warfarin. Medications containing Aspirin should also be avoided for a few days before and after the procedure.
What happens afterwards?
Almost all people who have fine needle biopsy have minimal discomfort and are able to return to normal activity immediately. A very small number of people will have some tenderness and bruising which may require minor analgesia or the application of an ice pack to the breast. The specimen slides are sent immediately to the pathologist. They usually issue a report within 48 hours. A copy of the report is sent directly to your own doctor by the pathologist.
SENTINEL LYMPH NODE BIOPSY
What is Sentinel Lymph Node Biopsy? * How is Sentinel Lymph Node Biopsy Performed? * Why is Sentinel Lymph Node Biopsy Performed? * What Happens When the Sentinel Lymph Node is Found to Be Cancerous? * What Are the Side Effects of a Sentinel Lymph Node Biopsy? * Is Sentinel Lymph Node Biopsy Accurate? * Are All Breast Cancer Patients Candidates for Sentinel Lymph Node Biopsy * Additional Resources and References *
What is a Sentinel Lymph Node?
Courtesy of Tyco
In the breast, a network of lymphatic vessels drain fluid and cells to the bean-shaped lymph nodes in the axilla (armpit). The “sentinel” node is the very first lymph node(s) to receive drainage from a cancer-containing area of the breast.
Put another way, when breast cancer cells begin to escape from the primary tumor site in the breast they travel to the lymph nodes under the arm; the first lymph node they reach is the 'sentinel' lymph node.
What is Sentinel Lymph Node Biopsy?
When breast cancer is diagnosed, women (and men) must often undergo axillary lymph node dissection (i.e., removal of underarm nodes) to check for the spread of cancer. This process is part of “staging” the cancer. Unfortunately, the removal of these lymph nodes can lead to lymphedema (chronic swelling) of the arm in a certain percentage-- about 10-20%--of cases.
Sentinel lymph node biopsy is a new diagnostic procedure used to determine whether breast cancer has spread (metastasized) to axillary lymph nodes (i.e., lymph glands under the arm). A sentinel lymph node biopsy requires the removal of only one to three lymph nodes for close review by a pathologist. If the sentinel nodes do not contain tumor (cancer) cells, this may eliminate the need to remove additional lymph nodes in the axillary area.
Early research on this technique indicates that sentinel lymph node biopsy may be associated with less pain and fewer complications than standard axillary dissection. However, because the procedure is so new, long term data are not yet available.
How is Sentinel Lymph Node Biopsy Performed?
Before going to the operating room, the surgeon injects a small dose of a low-level radioactive tracer called technetium-99 into the breast in the region of the patient’s tumor. Technetium-99 contains less radiation than a standard x-ray, CT scan or bone scan and is a relatively safe substance. A blue dye is also injected to help visually track the location of the sentinel node during surgery. The surgeon then uses a hand held counter to detect the radioactive tracer and locate the sentinel node.
Sometimes, nuclear medicine images (also known as lymphoscintigraphy) of the lymphatic system will be obtained after injecting the technetium-99 before surgery. Since the uptake of the technetium-99 by cancerous lymph nodes is sometimes different than the uptake by normal lymph nodes, these nuclear medicine images may also help show which lymph nodes are cancerous.
Next, the surgeon will wait for the technetium-99 and dye to travel from the tumor region to the sentinel lymph node(s), just as cancer cells might spread. Depending on the protocol followed, the surgeon usually waits between 45 minutes to 8 hours after injection before bringing a patient to the operating room for the biopsy. At some point during the procedure, a small amount of blue dye will also be injected into the breast tissue near the area of the tumor. Once the technetium-99 tracer and dye have reached the nodes, the surgeon will scan the area with an electric, hand-held gamma ray counter (called a Geiger counter) to detect the radioactive technetium-99.
The gamma ray counter is attached to a small probe which the surgeon traces over the axilla to locate the sentinel node(s). When the radioactive agent is found, the gamma ray counter will emit an audible tone, revealing the exact location of the sentinel node(s). Once the area has been pinpointed, the surgeon will make a small incision (usually one-half inch) and remove the sentinel node(s) for a pathologist to examine under a microscope. The blue dye provides additional visual confirmation of the sentinel node’s location during surgical removal. Several clinical trials have revealed that in the vast majority of cases, if the sentinel node does not contain cancer, then the cancer has not spread past the breast. Sentinel node biopsy does not usually require the placement of a fluid drainage tube (common in axillary node dissection).
Why is Sentinel Lymph Node Biopsy Performed?
Sentinel lymph node biopsy may help in determining which patients can avoid axillary node dissection and the removal of 10 to 30 lymph nodes. Most patients have only one to three sentinel lymph nodes under the arm. Thus, an average of only two lymph nodes are removed in each patient with a sentinel node biopsy. This, in turn, may reduce post-operative complications. A standard axillary node dissection, removal of the underarm lymph nodes, usually requires a larger four to six inch incision and a longer recovery period than a sentinel node biopsy.
Researchers are currently investigating whether sentinel node biopsy should routinely be performed in place of axillary node dissection. However, surgeons caution that more studies on the benefits and risks of sentinel node biopsy should be conducted before the procedure becomes widespread. Typically, patients who undergo a modified radical mastectomy or a lumpectomy may require lymph node removal. Sentinel node biopsy or axillary node dissection helps surgeons determine if breast cancer has spread to the lymphatics and the extent of the spread.
In a recent study published in The New England Journal of Medicine, 443 patients at 11 medical centers across the United States underwent sentinel node biopsies. Researchers discovered that if the gamma ray counter detected the radioactive agent (technetium-99) in the patients, then the sentinel node biopsy was 97% accurate in pinpointing all cancerous lymph nodes. However, the study was not completely successful. The gamma ray counter missed cancerous nodes in 13 of the 114 women whose cancer had spread past the breast. In an upcoming study, researchers at the National Cancer Institute will compare sentinel node biopsy to the standard method of lymph node removal (axillary node dissection) on 4000 women to determine which procedure is superior.
What Happens When the Sentinel Node Is Found To Be Cancerous?
After the surgeon removes the sentinel node(s), a pathologist will perform a preliminary examination of the nodes to determine whether they contain cancer cells. The sentinel lymph nodes will be classified as negative (no cancer), positive (contain cancer), or indeterminate. However, this preliminary report is followed by close examination and the final pathology report.
If the sentinel node is determined to be cancerous while the patient is still in surgery, the surgeon will usually remove additional lymph nodes in the axilla. However, the final pathology report is not available until after the surgery has been completed, and patients should schedule a follow-up visit with the surgeon to discuss the final report. Sometimes, the final report indicates a positive (cancerous) sentinel node that was not seen on preliminary review. If this occurs, then additional surgery may be necessary to remove more nodes for examination.
What Are the Side Effects of a Sentinel Lymph Node Biopsy?
Because sentinel lymph node biopsy involves removal of fewer lymph nodes than a standard axillary lymph node dissection, the potential for side effects such as lymphedema is much lower. Many patients who undergo sentinel node biopsy do not experience any side effects. However, some patients report post-operative pain, nerve damage, or lymphedema after the procedure. These symptoms occur more frequently when additional lymph nodes are removed along with the sentinel node.
The blue dye that is injected will turn the urine green for about 24 hours and may cause a temporary bluish discoloration of the breast skin. The radioactive energy from the technetitum-99 injection dissipates on its own, and some of the radiation is eliminated through urine or bowel movement. The result is that the radioactive material is only in the patient for a short time. Once the energy is eliminated, patients will no longer carry the radioactivity. The levels of radiation involved in a sentinel node biopsy are considerably lower than a patient would receive in a conventional x-ray study, bone scan or CT scan.
Most women who undergo sentinel node biopsy spend one day or less in the hospital. Occasionally, sentinel node biopsy may be performed on an outpatient basis.
Is Sentinel Node Biopsy Accurate?
Many surgeons agree that breast cancer may be accurately staged without having to remove any lymph nodes besides the sentinel node. Nevertheless, researchers are finding that a low percentage of sentinel node biopsy results can turn out to be “false negatives.” That is, the sentinel nodes do not contain cancer when, in fact, the patient’s other axillary lymph nodes do contain cancer.
This has been an important teaching point in many advanced courses presented to physicians who perform sentinel node biopsy. If a physician is uneasy about the looks of a sentinel node, even though it is not cancerous, the surgeon will typically remove additional lymph nodes to check their status.
The scenario of a negative (non-cancerous) sentinel node and positive (cancerous) additional nodes in a patient can occur for several reasons, including:
The timing of the dye injections
The type of dye/tracers used
The presence of more than one sentinel node
The way in which the initial node was sectioned or stained in the pathology lab
In July 2001, a steering committee of Health Canada's Canadian Breast Cancer Initiative conducted a systematic review of English-language literature on sentinel lymph node biopsy from 1991 to 2000. Based on their review, they cautiously endorsed sentinel lymph node biopsy, citing that it dramatically reduced side effects seen with standard axillary node dissection, such as wound infection, restriction of shoulder movement, arm problems, and lymphedema. However, the committee identified a main challenge of sentinel lymph node biopsy: that the procedure itself is difficult to master. Failure to correctly identify the sentinel node(s) and false positive results (mistakenly reporting that cancer is present) are two potential problems with the surgery. The committee cited research to support that performing several sentinel lymph node biopsies greatly increases a surgeon's accuracy at correctly identifying the sentinel lymph node(s) and reduces false positive results.
The American College of Surgeons Oncology Group recommends that physicians perform at least 30 sentinel lymph node biopsies followed by complete axillary node dissection, with an 85% success rate in identifying the sentinel lymph node(s) and a 5% or lower false positive rate. After they have accomplished this, physicians can then perform sentinel lymph node biopsy without a back-up axillary node dissection. According to the Canadian committee, physicians who have performed less than 30 sentinel lymph node biopsies should only perform the procedure as part of a clinical trial. Patients who are considering sentinel lymph node biopsy should ask their surgeon how many procedure he/she has performed and his/her success rate.
The committee also recommended that all patients be fully aware of the potential benefits and challenges of sentinel lymph node biopsy, including what is known and not known about the procedure. In particular, patients should be aware that there is a small chance (usually less than 10%) that the results of the sentinel lymph node biopsy can be inaccurate (false negatives); that is, there is no cancer in the sentinel nodes but cancer exists in other axillary lymph nodes. Missing these cancer cells can affect a patient's treatment after surgery and the chances that breast cancer may return.
To address some of the challenges of sentinel lymph node biopsy, the committee recommended guidelines for both physicians and patients:
Sentinel lymph node biopsies should only be performed by experienced physicians who have first familiarized themselves with literature on the procedure, have established a protocol for all aspects of the procedure, and have successfully performed back-up axillary node dissections on a sufficient number of patients.
Surgeons who do not often perform breast cancer surgery should not perform sentinel lymph node biopsy.
If a “positive” (cancerous) sentinel lymph node is found, a full axillary node dissection should be performed.
The report of the steering committee of Health Canada's Canadian Breast Cancer Initiative was published in the July 24, 2001 issue of the Canadian Medical Association Journal. Click here to learn more about this report.
Are All Breast Cancer Patients Candidates for Sentinel Lymph Node Biopsy?
Not all women with operable breast cancer who have been recommended to have some of their axillary (armpit) lymph nodes removed are candidates for sentinel node biopsy. According to a steering committee of Health Canada's Canadian Breast Cancer Initiative, the following women are poor candidates for sentinel lymph node biopsy:
Women with palpable (able to be felt) lymph nodes
Women with locally advanced breast cancer
Women with multi-focal breast cancer (cancer in many areas of the breast)
Women who have previously undergone breast surgery (including breast reduction)
Women who have previously undergone radiation therapy to the breast
Women should discuss the benefits and risks of sentinel lymph node biopsy with their cancer treatment team.
Additional Resources and References
The American Cancer Society provides information on sentinel node biopsy at http://www.cancer.org/
The October 1, 1998 article, "Sentinel-Lymph-Node Biopsy for Breast Cancer -- Not Yet the Standard of Care," was published in The New England Journal of Medicine, http://www.nejm.org/
The American Society of Breast Surgeons provides information on select clinical trials, including several involving sentinel node biopsy at http://www.breastsurgeons.org/
BreastDoctor.com provides more than 30 pages on sentinel node biopsy and lymph nodes at http://www.breastcancer.com/
Introductory and advanced explanations of sentinel node biopsy are included.
An abstract from the medical report, “Sentinel Node Biopsy in Breast Cancer: Results of 103 Cases,” that appeared in the February 2000 issue of Australian And New Zealand Journal Of Surgery is available at http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve& br / db=PubMed&list_uids=10711469&dopt=Abstract
When Compression Is Not Appropriate
Dr. Reid's Corner
Post Reconstructive Breast Surgery
I frequently get questions from my patients concerning the use of compression following reconstructive breast surgery. Most patients develop swelling and edema following reconstructive surgery. However, this edema and swelling subsides following the surgery and I do not recommend the use of compressive garments for the management of edema for these patients. In fact, the use of compression can be harmful. Just like the case of the scrotal edema above, the tissue following reconstruction is delicate. To perform the reconstruction a section of skin with the muscle and blood supply is moved from the abdomen to the chest wall. This section of tissue needs time to securely grow in place. The application of compression can cause diminished blood flow and the graft may complicate the procedure. Common complications include blood clots in the vessels, partial or complete loss of the tissue flap, skin necrosis, and local wound-healing problems. The use of compression could increase the risk of blood clots and increase the risk of loss or necrosis of the reconstructed breast. The expected complication rate for this type of surgery is in the range of 2 to 6% but can be significantly higher. Recent studies demonstrate that smokers and patients who are significantly over weight have a higher complication rate. In addition, recent studies have shown that smoking and obesity, which impair normal blood flow and tissue healing, significantly contribute to complications from reconstruction (see abstracts below). Since most swelling and edema following reconstructive surgery will resolve as the tissues heals, the use of compression to reduce edema is of limited value and can cause complications. Only your doctor will be able to evaluate your particular condition and determine if there is any role for compression following reconstructive surgery. For additional information on reconstruction, see Dr. Reid's Corner here.
Tony Reid, MD Ph.D
Sentinel Node Biopsy Update (5-19-03)
Dr. Reid's Corner
I have taken a few months off from writing the Lymphedema eNews
this time I have reported the results of a clinical trial using a new
for patients with metastatic cancer of the colon. This trial uses a new
gene therapy based on the common cold virus. While still early, the
this trial is very encouraging (USA today article). The gene therapy
is still in the early stages of development; however, I hope to someday
to write that the promise of gene therapy has helped not only treat
helped to control and perhaps cure lymphedema. Until we reach that
is a lot of work to be done and we will continue our efforts to provide
effective treatments for lymphedema.
A sentinel node biopsy is a technique that may help limit the number of axillary dissection that are performed for breast cancer. Since the extent of an axillary dissection is related to the incidence of lymphedema, the use of sentinel node biopsies instead of an axillary dissectioin may reduce the risk of developing lymphedema. I have previously discussed the issue of sentinel node biopsies (Sentinel Node Biospy,Sentinel Lymph Node Biopsy: Study Update,Follow up on the sentinel lymph node biopsy). A question that has not been fully answered is whether a limited technique such as sentinel node mapping is as accurate as an axillary dissection. In a recent study, 343 women underwent both sentinel node mapping and an axillary dissection. 125 of the 343 women had a positive sentinel node and 218 had negative sentinel nodes after pathological analysis. Of the 125 with involved sentinel nodes, almost half were found to have additional lymph nodes involved with cancer when the axillary dissection was performed. Therefore, a positive sentinel node suggests that the likelihood of finding additional involved lymph nodes is about 50% and that further studies including an axillary dissection may be needed to remove all detectable cancer. Among the 218 women where the sentinel lymph node was negative, 15 were subsequently found to have involved lymph nodes when the axillary dissection was performed. Taking a look at the group as a whole, of the 343 women who were studied, 125 had lymph nodes correctly identified by sentinel node biopsy and 15 had lymph nodes that were missed. Therefore, 140 (125 by sentinel node and 15 by axillary dissection) women had positive lymph nodes and 15 of the 140, approximately 10%, were missed by the sentinel node technique. Efforts are being made to further improve on the results of sentinel node biopsies. To perform the sentinel node biopsy a blue dye or a radiographic tracer are placed under the skin. These tracers drain to the regional lymph node which is then identified and surgically removed for inspection by the pathologist. These two techniques were compared in a study of 814 women. The dye method correctly identified the sentinel node in 72% of the cases and the radiographic tracer correctly identified the sentinel node in 79% of the cases. The best results were obtained with a combination of the two methods. When both techniques were used together the detection rate increased to 90%. As has been found in most studies, the predictive value of the tests were highest in the hands of experienced physicians. In my opinion, the sentinel node biopsy is a great step forward. Using this test we hope to significantly reduce the number of unnecessary axillary dissections that are preformed each year and as a result we hope that the number of women who develop lymphedema will be dramatically lower in the future. Further work to improve this technique is underway. However, as is always the case in medicine, there are limitations to any technique. In about 10% of cases the cancer cells do not go to the sentinel node. If this happens, the sentinel node biopsy will show no evidence of cancer and lymph nodes involved with cancer will be missed. It is also important to recognize that not all patients are good candidates for sentinel node biopsies. The sentinel node biopsy is most effective in women who have only one tumor mass in the breast that is less that about an inch in size. If there are several tumor masses or if the tumor mass is large, the sentinel node biopsy is much less reliable. In addition, if lymph nodes can be detected by either physical exam or by ultrasound, then the probability of involvement multiple lymph nodes with cancer is high. Finally, sentinel node biopsy is more reliable among women who have not had prior surgery. Prior surgeries including lumpectomies can alter the lymphatic flow and, as a result, reduce the reliability of sentinel node mapping. In a related news story, the survival rates among women who have recurrent breast cancer were compared for the last 25 years. 25 years ago if a woman underwent treatment for cancer and then had the cancer reappear, the expected survival was a little more than 1 year and only 10% of women were still alive 5 years later. Over the last 25 years new treatments have been introduced including better chemotherapeutic and hormonal drugs. In addition, better techniques for early detection have been developed and implemented. As a result, a woman today whose cancer comes back after the initial treatment, has an average expected survival of nearly 4 years. Over 40% of these women live longer than 5 years. We have made a tremendous amount of progress over the last 25 years and we will continue the fight against cancer and lymphedema. I expect that we will see the rates for lymphedema decrease considerably over the next 25 years and several of the necessary tools are available now. Early detection and treatment of breast cancer is critical. If most cancers can be detected while they are small, then sentinel node biopsies will be sufficient and most axillary dissections can be avoided. You can help prevent lymphedema by taking steps to catch breast cancer early. Be aware of the warning signs of cancer, perform monthly self-examinations, have regular mammograms and see your doctor regularly.
Tony Reid MD, Ph.D.
Follow up on the sentinel lymph node biopsy
Dr. Reid's Corner
I have taken a few months off from writing the Lymphedema eNews
this time I have reported the results of a clinical trial using a new
for patients with metastatic cancer of the colon. This trial uses a new
gene therapy based on the common cold virus. While still early, the
this trial is very encouraging (USA today article). The gene therapy
is still in the early stages of development; however, I hope to someday
to write that the promise of gene therapy has helped not only treat
helped to control and perhaps cure lymphedema. Until we reach that
is a lot of work to be done and we will continue our efforts to provide
effective treatments for lymphedema.
In two issues of Lymphedema eNews, I have reported on the use of sentinel lymph node biopsy. A recent report raises an important question about when sentinel lymph node dissections can be safely used without risk of leaving behind lymph nodes involved with cancer. To help put the issue in perspective, I will summarize some of the discussion from my previous articles.
The status of the lymph nodes is the most important single prognostic factor for breast cancer. Cells from cancers of the breast will break off from the cancer and migrate through the lymphatic channels to the regional lymph nodes. As a result, removal of the lymph nodes serves two functions. First, the nodes can be studied under the microscope. If there are no cancer cells in the lymph nodes, the risk of recurrence of the cancer is much lower than if there is metastatic cancer in the lymph nodes and less aggressive treatment is required to control the cancer. Patients with cancer in their lymph nodes will require additional treatment and their chance of recurrence of the cancer is higher. Second, if the cancer does involve the lymph nodes, removal of as much of the cancer as possible is important to reduce the chance that the cancer will come back in the involved lymph nodes in the axilla.
In a traditional axillary dissection, a portion of the tissue in the axilla where the lymph nodes are found is removed. The lymph nodes are small structures, about the size of a small pea, located throughout the body. They serve as immunological filters to protect the body that primarily function to protect the body from infections. Cancer cells from the breast will migrate to the lymph nodes in the axilla where there are over 50 small lymph nodes. To determine whether there is cancer in the lymph nodes, a sample of 5 to 10 of these nodes are removed surgically and studied under the microscope. The risk is that as more lymph nodes are removed, the probability of developing lymphedema increases.
The sentinel lymph node biopsy is essentially minimal surgery. Instead of removing 5 to 10 nodes, the sentinel node biopsy removes the one lymph node most likely to have cancer cells. To do this, a new technique has been developed that uses a combination of a radioactive tracer and a color dye. The dye is injected around the tumor or into the biopsy cavity. The dye will migrate through the lymphatic channels to the regional lymph nodes drained by the cancer. The specific node most likely to be involved with cancer is then identified and removed for microscopic analysis.
New Computerized Tool Predicts Chance of
Researchers at Memorial Sloan-Kettering Cancer Center (MSKCC) have
developed a new computerized tool called a nomogram that will help patients and their physicians calculate the likelihood of breast cancer spreading beyond the sentinel lymph nodes to additional lymph nodes under the arms (axilla). Further axillary lymph node metastasis is a key factor in determining whether a patient is likely to benefit from additional surgery to remove all of the nodes.
Touch Preparation or Frozen Section for Intraoperative Detection of Sentinel Lymph Node Metastases From Breast Cancer
Lack of Effect of Coumarin in Women with Lymphedema after Treatment for Breast Cancer
Background: Lymphedema of the arms can be a serious consequence of local and regional therapy in women with breast cancer. Coumarin has been reported to be effective for the treatment of women with lymphedema; we undertook a study in which we attempted to replicate those findings.
Methods: We studied 140 women with chronic lymphedema of the ipsilateral arm after treatment for breast cancer. The women received 200 mg of oral coumarin or placebo twice daily for six months and then the other treatment for the following six months. The end points of the study consisted of the volume of the arm (calculated from measurements of hand and arm circumference) and the answers on a questionnaire completed by the patient about symptoms potentially related to lymphedema.
Results: The volumes of the arms at 6 and 12 months were virtually identical, regardless of whether coumarin or placebo was given first. After six months, the average volume of the affected arm increased by 21 ml during placebo treatment and 58 ml during coumarin treatment (P=0.80). In addition, answers on the patients' questionnaires were similar in the two treatment groups. After six months, only 15 percent of the women in the coumarin group and 10 percent of those in the placebo group reported that the study medication had helped a moderate or large amount (P=0.19). Coumarin was well tolerated, except that it resulted in serologic evidence of liver toxicity in 6 percent of the women.
Conclusions: Coumarin is not effective therapy for women who have lymphedema of the arm after treatment for breast cancer.
Axillary Treatment in Conservative
Operable Breast Cancer: Dissection or Radiotherapy? Results of a
Study With 15 Years of Follow-Up
The sensitivity of axillary staging when using sentinel node biopsy in breast cancer
European Journal of Surgical Oncology, Volume 29, Issue 10, Pages 849-853
M. Leidenius, L. Krogerus, T. Toivonen, E. Leppänen and K. von Smitten
ABSTRACT: Lymphedema after treatment of
[01/06/2004; American Journal of Surgery]
Background: Lymphedema is one of the major long-term complications
of axillary dissection. This study was designed to investigate
the risk factors that are predicted to effect the development
of lymphedema after complete axillary dissection.
Results: Lymphedema developed in 68 (28%) of the 240 cases. Axillary
radiotherapy and body mass index were found to increase
the incidence of the lymphedema.
Conclusions: Women who had the combination of full axillary
dissection and axillary radiotherapy carry a significant risk
The full article can be found at:
What Every Woman With Breast Cancer Should Know
What Every Woman Facing Breast Cancer Should Know About Lymphedema: Hand and Arm Care Following Surgery or Radiation Therapy for Breast Cancer
American Cancer Society
Coping with Lymphedema - Book
For Breast Cancer Survivors, Lymphedema Adds Insult to Injury
By Michael Toscano
Reprinted from the Associated Press
December 23, 2003
Lymphedema, a painful and often debilitating buildup of lymphatic fluid in an arm caused by removal of the lymph nodes, is an often overlooked aspect of breast cancer treatment.
A 1998 report estimated as many as a third to a half of the nearly 200,000 women diagnosed with breast cancer each year develop the chronic condition following traditional surgery, in which all lymph nodes in the armpit nearest the affected breast are routinely removed and biopsied. (Radiation treatment may increase the risk.) A 1999 medical report put the number of people with lymphedema resulting from breast cancer in the United States at 400,000. But because there has been little monitoring of lymphedema patients, good data are scarce.
One reason there's been so little tracking: The disorder can manifest itself any time from three months to more than 30 years after surgery, say breast cancer surgeons. As thick, protein-rich fluid that is normally removed by lymph nodes begins to clog tissues, the patient's arm starts to ache and swell. The swelling can interfere with sleeping, lifting and walking and can make people more susceptible to infection. There is no cure; symptoms are generally managed with physical therapy, massage and exercise. Compression bandages are also used sometimes.
A study published earlier this year in the journal Cancer found that about 39 percent of 153 breast cancer survivors reported some level of lymphedema two decades after surgery, and that the condition caused them considerable stress.
The psychological impact doesn't surprise Chevy Chase physical therapist Janet Sobel, who sees about 20 lymphedema patients each week. "Number one, it's a constant, daily reminder that they've had breast cancer," she says. "Plus, it's cosmetically unattractive. For some people, it's very painful and they're always dealing with people asking what happened to their arm. They have trouble doing everyday things, like picking up a child, and have trouble buying normal clothes in normal stores because one arm may be bigger than the other."
Changes in surgical procedures may reduce the incidence of lymphedema. According to Ted Tsangaris, associate professor of surgery at Baltimore's Johns Hopkins School of Medicine and head of breast surgery at Johns Hopkins Hospital, the primary reason for the traditional removal of lymph nodes, which can range in number from five to 40, is diagnostic -- to determine whether the cancer has spread beyond the breast. "It was a very crude way of approaching it," said Tsangaris. "You just automatically took out most of the lymph nodes underneath the arm, handed them to a pathologist, and said, 'Find me a lymph node that has cancer.' "
But a more targeted surgical approach, called sentinel node biopsy, may make lymphedema less likely because many lymph nodes are spared. Surgeons first inject dyes into the breast. The dyes are observed to see if they travel into the lymph nodes, mimicking the pathway cancer cells might have taken. If dyes are found in a lymph node, it is removed to determine if it is cancerous. The rest of the nodes are left intact.
"If there's no cancer in the lymph nodes identified as being sentinels," said Tsangaris, "studies have shown with very good reliability that you can predict that the rest of the lymph nodes are going to be negative. You don't take them out and, therefore, the risk of lymphedema is essentially almost zero."
However, he noted, the surgery is new enough and demanding enough that many doctors are not comfortable doing it; it also requires the patient to take on a higher degree of risk: "If you take out the wrong lymph node and you tell the patient there is no cancer in the lymph nodes, it's possible she won't get any chemo or other therapy and will be under-treated."
Breast cancer surgeon Nancy Markus, who practices at Shady Grove Adventist Hospital in Rockville, says she recommends that her patients follow prescribed physical exercises and weight control -- both, she says, major factors in reducing the risk of lymphedema. "Usually," she said, "if they are diligent about doing their exercises, they don't have much of a problem with lymphedema, unless there's some inciting event to trigger it. . . . Anything that causes an inflammation in the affected arm can set it off, and once it starts, it is very difficult to completely eliminate it.
"I tell my patients to avoid constricting garments on their arm and if they get a cut or any break in the skin, to immediately treat it with an antibiotic ointment," she explained. "If redness occurs, they need to contact us for prompt antibiotic therapy because an infection can easily trigger the lymphedema."
Surgical treatment for lymphedema is reserved for only the most severe cases and has a low success rate.
Benita J. Walton, founder of Casting For Recovery, says no formal study has followed any of the program's 1,200 retreat participants to see if they've accrued any benefits, including warding off lymphedema. She says she is drafting grant proposals to do just that.
Markus recommends that women seeking more information about lymphedema contact the Mid-Atlantic Lymphedema Centers at 800-845-7525, the American Cancer Society at 800-227-2345 or www.cancer.org, the National Lymphedema Network at 800-541-3259 or www.lymphnet.org, or the Susan G. Komen Breast Cancer Foundation at 800-462-9273 or www.breastcancerinfo.com.
-- Michael Toscano
The Washington Post Company
*Source link no longer available
Women's experiences of
Corry College, Milton, MA, USA.
PURPOSE/OBJECTIVES: To explore women's experiences of lymphedema.
DESIGN: Qualitative descriptive.
SETTING: An urban community in the midwestern United States.
SAMPLE: Ten women who experienced lymphedema after breast cancer treatment and who had (a) completed their treatment for stage I or stage II breast cancer at least one year before the study, (b) experienced an onset of lymphedema at least two months after surgery, (c) no current evidence of cancer disease or cancer recurrence, (d) lymphedema not caused by cancer in the brachial plexus, and (e) no history of hospitalization for alcoholism, substance abuse, or psychiatric conditions. The women ranged in age from 36-75 years. Mean survival time was seven years, and the mean time since onset of lymphedema was four years.
METHODS: Two in-depth interviews per participant.
PATIENTS: Most women were able to continue living their normal lives. Some women experienced depression, anxiety, and impairments related to their intimate, work, and social relationships. Physicians' limited knowledge about lymphedema, conflicting treatment information, and the limited number of available treatment centers caused distress for the participants. Their experiences can be categorized into three predominant themes: Abandonment by Medicine, Concealing the imperfect image, and Living the Interrupted Life.
CONCLUSIONS: Research efforts to expand the knowledge base regarding the epidemiology, prevention, and treatment of lymphedema are needed. Also needed is research that explores the impact of lymphedema on quality of life and functional ability as well as the psychosocial impact of lymphedema on body image, self esteem, and social support.
IMPLICATIONS FOR NURSING PRACTICE: Care providers and breast cancer
should be educated about the prevention and treatment of lympedema.
should refer patients to advocacy hot lines and support groups for
and support when appropriate. Women with lymphedema should be assessed
periodically for psychosocial distress and referred for care as needed.
PMID: 9201739 [PubMed - indexed for MEDLINE]
Treatment of Lymphedema Related to Breast Cancer
Evidence Summary Report #13-1
Klligman L, Wong R, Johnston M, Laetsch N and the Members of the
Supportive Care Guidlines Group
Reported Date: August 22, 2003
Massage Therapists and Breast Care: Easing the ControversyBy Bruno Chikly, MD, DO (hon)
|Bruno Chikly, MD, DO (hon) is a graduate of the medical school at Saint Antoine Hospital in France, where his internship in general medicine included training in endocrinology, surgery, neurology and psychiatry. He is author of the first comprehensive book in North America on the lymphatic system and lymphedema, Silent Waves: Theory and Practice of Lymph Drainage Therapy.|
Breast massage is often the subject of ardent controversy, due to the legal, ethical and physical problems associated with it. Because of this, many practitioners are reserved when it comes to working on this area of the body. It is my hope that the information and guidelines provided in this article will ease the debate. I have taught and provided therapeutic breast care for many years using techniques that work through the lymphatic system. While I understand the reason for the controversy, I know that respectful, nonstimulating and effective techniques for breast care do exist. However, these must be practiced in a specific and controlled environment by qualified therapists who clearly understand the boundaries. Within this context and scope of practice, breast care can be safely and efficiently applied to alleviate numerous breast pathologies.
Guidelines for Therapeutic Breast Care
Through my experience, I have developed some general guidelines for application that should help to eliminate most of the controversy surrounding this treatment:
1. Therapists should know the rules and/or laws regarding breast massage that govern their licensure in the city/state/country in which they practice.
2. Contraindications and precautions must be respected related to the specific pathology and technique being used.
3. Heavy pressure should not be applied to the breast tissue. All that prevents breast tissue from sagging (mastoptosis) are some minute elastic fibers of the superficial skin and a few suspensory ligaments (Cooper's ligament), which are actually comprised more of irregular layers of connective tissue fibers than of real organized ligaments.1 Petrissage (kneading) may hurt or destroy the few existing local suspensory ligaments and elastic fibers. Women with breast implants present another area of caution, as too much pressure may cause leaking.
4. There are a number of techniques that are gentle, noninvasive and nonstimulating. Efficient work can be accomplished without ever using stimulating touch. Remember, breasts are created to nurture and support the growth of a newborn; they need to be touched in a respectful and gentle manner. I also suggest that therapists speak gently during a breast treatment.
5. Prior to any session, therapists should clearly explain what the session will entail, along with its objectives and intentions. Have the client sign a release form consenting to the treatment. This form should explain why and how this technique is applied. The form should state that a client has the right to stop the massage at any time whatsoever.
6. Therapists should remain aware of the trust clients have placed in them to provide breast care. Proper draping should be used at all times to provide the client maximum comfort and security.
7. I recommend self-application techniques (self-lymphatic breast care) to clients as a way to enhance the effects of the session. The protocol is also an excellent option for clients who may not feel comfortable having the technique applied by a practitioner.
Lymph Drainage Therapy for Breast Health:
Lymphatic Breast Care
Study of the body's lymphatic system shows that breast tissue contains an abundance of lymph vessels. Unlike other areas of the body, however, the breast lacks sources of external compression, such as muscles or strong overlying fascia that promote natural lymphatic drainage. As a result, fluid has a tendency to stagnate, which may lead to breast pathologies (mastopathy). This is where gentle, nonstimulating techniques can be applied to aid fluid recirculation. Of the many modalities I have studied and practiced throughout my career, lymphatic work is always the first approach I turn to in treating the breast.
Lymph drainage therapy (LDT) is a gentle, nonstimulating technique with few contraindications. It teaches practitioners how to attune to the precise rhythm, direction, depth and quality of the lymph flow. LDT is particularly effective for treating breast tissue because it involves extremely light pressure - generally no more than the equivalent weight of a dime or nickel. I am amazed at the applications and efficiency of lymph drainage therapy in treating most breast pathologies. Numerous mastopathies respond well to lymphatic breast care.
The multiple applications and benefits of LDT for mastopathies are simply too important, however, not to be implemented. Manual lymph therapies are established medical procedures used nationwide in clinics and hospitals, and are reimbursed by Medicare, primarily for their efficiency in alleviating edema and lymphedema.
IIt is time for gentle and efficient breast care to be brought into the realm of accepted practice. Armed with knowledge and a clear understanding of boundaries, we can eliminate the controversy surrounding this legitimate, necessary therapeutic application.
1. Chikly B.
Dissection of the Human Lymphatic System, Video 2.
(Editor's note: This video is available through the International Alliance of Healthcare Educators (IAHE) at www.iahe.com.)
Chikly, MD, DO (hon)
Breast Cancer Organizations, Support Advocacy
Step Up, Speak OutBreastcancer.org
The Breast Care Site
Pink Ribbon Breast Cancer Resource Guide
Cancer Association of Nova Scotia
- Y Me National Breast Cancer Organization
theCancer.info Breast Cancer Links Page
Articles concerning breast cancer and lymphedema
After Breast Cancer Treatment
Lymphedema: A Breast Cancer Patient's Guide to Prevention and Healing
by Jeannie Burt, Gwen White, Judith R. Casley-Smith
http://www.amazon.com/exec/obidos/tg/detail/-/0897932641? br / v=glance
Lymphovenous Canada: Cancer and Lymphedema
Awareness: Before, During And After Breast Cancer Surgery
Saskia R.J. Thiadens, R.N. 1998
article: Pain in the Lymphedematous arm following treatment of breast
evaluation and treatment
Article: Introduction and Treatments for Lymphedema
Sabrina S. Selim, BA, Francine Manuel, RTP, Cheryl Ewing, MD, Ernest H. Rosenbaum, MD
Breast cancer metastasis: a microRNA story
Breast Cancer Gene Ringleader Found
Gene Signatures ID Bad Breast Cancers
All about Breast Cancer Genes
Breast Cancer (BRCA) Gene Test
Familial breast cancer: characteristics and outcome of BRCA 1-2 positive and negative cases.
People Cancer Information Pages
Cervical, ovarian Cancer
Kidney and Renal Cancer
Hodgkins Disease or Hodgkins Lymphoma
Leg Lymphedema After Gynecological Cancer
Primary Lymphedema and Cancer
Cutaneous T-cell Lymphoma
Cutaneous B-cell Lymphoma
My Life with Lymphedema and Lymphoma
Lymphedema Affects Quality of Life
Angiosarcoma and Long Term Lymphedema
Male Breast Cancer
Lymphedema After Cancer - How Serious Is It?
Secondary Lymphedema in the Cancer Patient
Complications of Breast Cancer Radiotherapy
Complete decongestive therapy lymphedema in breast cancer
Patient self-massage for breast cancer-related lymphedema
Predictive Factors of Response to Intensive Decongestive Physiotherapy in Upper Limb Lymphedema After Breast Cancer Treatment: a Cohort Study
Lymphedema Therapy and the Quality of Life for Breast Cancer Patients
Cancer Associated with Lymphedema
Pseudolymphomatous Cutaneous Angiosarcoma: A Rare Variant of Cutaneous Angiosarcoma Readily Mistaken for Cutaneous Lymphoma.
Papillomatosis cutis carcinoides
Related Terms: Verrucous Carcinoma, Squamous Cell Carcinoma, Epithelioma cuniculatum, Carcinoma cuniculatum
Cutaneous lymphomas assoc with lymphoproliferative disorders
Aqua Lymphatic Therapy for Postsurgical Breast Cancer Lymphedema
Sporadic Cutaneous Angiosarcomas
Axillary node biopsy
Sentinel Node Biopsy
Small Needle Biopsy - Fine Needle Aspiration
Extraperitoneal para-aortic lymph node dissection (EPLND)
also includes (1) Retroperitoneal Lymph Node Dissection and (2) Laparoscopic Retroperitoneal Lymph Node Dissection
Magnetic Resonance Imaging
Lymphedema People Online Support Groups
MEN WITH LYMPHEDEMA
If you are a
man with lymphedema; a man with a
loved one with lymphedema who you are trying to help and understand
come join us
and discover what it is to be the master instead of the sufferer of
Join us as we work for lymphedema patients everywehere:
Advocates for Lymphedema
Dedicated to be an advocacy group for lymphedema patients. Working towards education, legal reform, changing insurance practices, promoting research, reaching for a cure.
Lymphedema People / Advocates for Lymphedema
For information about Lymphedema
For Information about Lymphedema Complications
For Lymphedema Personal Stories
For information about How to Treat a Lymphedema Wound
For information about Lymphedema Treatment
For information about Exercises for Lymphedema
For information on Infections Associated with Lymphedema
For information on Lymphedema in Children
About Lymphangiectasia Yahoo Support Group
Support group for parents, patients, children who suffer from all forms of lymphangiectasia. This condition is caused by dilation of the lymphatics. It can affect the intestinal tract, lungs and other critical body areas.
Our Home Page: Lymphedema People
Updated Jan 15, 2012