7/12/2016. The Biology and Management of Lymphedema in the Breast Cancer Survivor. Learning Objectives. Lymphedema- Why is it important?

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1 The Biology and Management of Lymphedema in the Breast Cancer Survivor Shirley Mandeville FNP, BC Surgical Oncology Comprehensive Breast Care at Pluta Wilmot Cancer Institute Learning Objectives Describe factors in disease and treatment of breast cancer patients that puts them at risk for lymphedema of the breast and/or arm Discuss strategies to minimize the occurrence of lymphedema in the breast cancer patient Describe signs/symptoms and appropriate interventions at each stage of lymphedema 2 Lymphedema- Why is it important? Lymphedema is estimated to occur in 25% of women with breast cancer with a range of 6-68% depending on treatment. (Yarbro, 2011). The Institute of Medicine recommends measures to prevent this complication be included in every Breast Cancer Survivor Care Plan. It can be a significant cause of decreased function and quality of life. 3 1

2 4 3 functions of lymphatic System Balance fluid within tissues Transport cells involved in immune response Remove proteins and particles of cellular debris from the tissue spaces 5 Lymphedema basics Lymphedema is the build-up of fluid in soft body tissues when the lymph system is damaged or blocked. 6 2

3 Lymphedema Disruption of lymphatic system load > capacity Protein- rich fluid pushed into interstitial space Decreased ability to fight infection 7 Anatomy lymphatic drainage 8 Breast cancer survivor with left arm lymphedema after Modified Radical mastectomy and axillary radiation treatment (Tiwari, 2013) 9 3

4 Causes of lymphedema in the breast cancer survivor Breast cancer pressing on or invading lymph system Axillary node surgery (sentinel or complete dissection) Radiation Chemotherapy especially Taxanes short term Obesity Infection 10 Landmark Studies that are changing practice ACOSOG-Z0011- no significant decrease in survival with SNL dissection alone compared to complete ALND in women with early stage breast cancer (T1 and T2) who had lumpectomy and breast irradiation and any appropriate systemic therapy AMAROS trial- ALND versus radiation of the ALNs showed similar risk of recurrence reduction in node positive patients but with less lymphedema. 11 How Often Does It Really Occur? Actual Incidence Depends on Cancer Treatment & Type 4

5 13 Commonly accepted prevention guidelines Self-monitoring by patient for changed in size or puffy appearance of breast and/or arm,(change in how watch, bracelet, clothes or rings fit) sensation (heaviness, skin feels tight), color, temperature and skin condition of the affected breast and arm Avoid blood pressures, blood draws, IVs, shots in the affected arm Avoid prolonged periods of arm in dependent position and wear a good support bra Maintain ideal body weight Exercise is good to mobilize lymph flow but should start low and progress gradually, perhaps using compression garments Avoid skin infection or injury with good skin and nail care, sun protection, preventing pet scratches and insect bites, avoiding hot tubs and sauna- prompt treatment of cellulitis or infection Air flight risk is controversial but compression garment may be appropriate especially for longer flights 14 Diagnosis of Lymphedema Important differentials - As blood clot risk is higher in an oncology patient a venous ultrasound is sometimes considered especially if occurs rapidly. Also, consider new disease compressing/blocking lymphatics. History: patient description of sensations or appearance of arm and/or breast and especially when it occurred in relationship to any activities (carrying groceries, kayak trip, hot weather) Exam: Visual inspection, palpation of tissue Measurement: (next slides) 15 5

6 Measures of Lymphedema (Simona, 2014) Water displacement Tape measurements 16 Further measures of lymphedema Perometry measure Bioimpedence (BIS) (Simona, 2014) 17 Bioimpedence spectroscopy Low frequency electric signal won t pass cell wall the more extracellular fluid, as in lymphedema, the higher the reading 18 6

7 Lymphedema Assessments Adapted from Ward, L.C., Bioelectrical impedance analysis: proven utility in lymphedema risk assessment and therapeutic monitoring. Lymphat Res Biol, (1): p Stages of Lymphedema in Arms (photos by Dr. Charles McGarvey and Guenter Klose) 21 7

8 Stage 0 Lymphedema No apparent swelling May report vague heaviness Slower flow on Lymphoscintigraphy Detectable with BIS (L-Dex) Stage 1 Lymphedema Mild swelling Reversible with elevation of the arm Protein-rich extracellular fluid Detectable with all techniques Stage 2 Lymphedema Mild to moderate swelling Minimal or no decrease with elevation Expanded extracellular fluid compartment Fibrosis: lifelong Complete Decongestive Therapy (CDT) too late for prevention 8

9 Stage 3 Lymphedema Severe swelling No change with elevation Fibrosis and fat have replaced most of the fluid Little response to CDT (complete, complex, comprehensive) Breast Lymphedema Prevention: Well fitting/lifting bra Treatment: compression bra and sometimes compression shirt Lymphatic stimulation and self-drainage techniques Chip bag with small pieces of multiple density foam added to bra at firmer area Therapeutic ultrasound Complications: cellulitis or lymphangitis requiring antibiotic (note mild pink without other factors can be the edema itself) 26 Conclusion Whatever your role, you will encounter breast cancer survivors. Your attention to prevention and/or early treatment of lymphedema can have a significant positive impact on their quality of life. Questions? 27 9

10 References Knowlton, J. and Mandeville, S., The Biology and Management of Lymphedema in the Breast Cancer Patient. to be published August Mohler E and Mehrara B (2016) Clinical Staging and Conservative Management of Peripheral Lymphadenopathy.Up to Date, 2016 retrieved from of peripheral-lymphadenopathy on June 28, National Cancer Institute. At the National Institute of Health. Lymphedema (PDQ) Health Professional Version. Retrieved from on April 21, Shaitelman, S. F., Cromwell, K. D., Rasmussen, J. C., Stout, N. L., Armer, J. M., Lasinski, B. B. and Cormier, J. N. (2015), Recent progress in the treatment and prevention of cancer-related lymphedema. CA: A Cancer Journal for Clinicians, 65: doi: /caac References continued Soran A, Ozmen T, McGuire KP, Diego E, McAuliffe P, Bonaventura M, Ahrendt G, DeGore L, and Johnson R (2014). The importance of detection of subclinical lymphedema for the prevention of breast cancer-related clinical lymphedema after axillary lymph node dissection; A prospective observational study. Lymphatic Research and Biology, 12(4): Tiwari P, Coriddi M, Salani R, Povoski SP. Breast and gynecologic cancer-related extremity lymphedema: a review of diagnostic modalities and management options. World Journal of Surgical Oncology. 2013;11:237. doi: / Yarbro C, Wujick D, and Gobel B (2010) Cancer Nursing Principles and Practice, (Ed. 7) Sudbury MA: Jones and Bartlett

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