Compression therapies: Hosiery, multilayer wraps, or ...

Compression therapies: Hosiery, multilayer wraps, or ...

LYMPHEDEMA AND BREAST CANCER THERAPY IMPACT OF IDENTIFYING HIGH-RISK PATIENTS AND EARLY INTERVENTION Atilla Soran, MD, MPH, FNCBC, FACS Professor of Clinical Surgery Breast Surgical Oncologist Director, Comprehensive Lymphedema Program Magee-Womens Hospital of UPMC WHAT IS LYMPHEDEMA? SWELLING: PROTEIN RICH FLUID ACCUMULATION CAUSES OF LE ; REMOVAL OR DAMAGE OF THE LN SURGERY

RT CVI INFECTION TRAUMA MUSCLE STRAIN GENETIC DEFECT IN THE LYMPHATIC SYSTEM CANCER TREATMENT FACTORS DEMOGRAPHIC FACTORS LND HAND DOMINANCE GREATER NUMBER OF LYMPH NODES DISSECTED

Extensive surgery AGING RT EDUCATION CT GENETIC DISPOSITION HIGHER STAGE OF DISEASE POSTOPERATIVE INFECTION

Cancer RLE RISK FACTORS LIFE STYLE AND BEHAVIORS HIGHER BODY MASS INDEX (>25 OR >30 KG/M2) LESS REGULAR PHYSICAL ACTIVITY PHLEOBOTOMY AND BLOOD PRESSURE READINGS TAKEN ON THE TREATED SITE ??? NO PREVENTIVE SELF-CARE ACTIVITIES PRESENCE OF COMORBIDITIES, ALCOHOL, SMOKING HIGH BLOOD PRESSURE OCCUPATION REQUIRING A HIGH LEVEL OF HAND USE NO PRE-POST TREATMENT EDUCATION ON LYMPHEDEMA MWH Experience ( 36th Miami Breast Cancer Conference-3/19 Other includes segmental mastectomy/ lumpectomy/ reexcision

Lymphedema No % (n=2893) Lymphedema Yes % (n=47) P Mean Age at diagnosis + SD 59.9 + 12.4 59.1 + 10.6

0.66 BMI > 25 Kg/m2 68.4 (1740) 65.9 (29) 0.72 BMI > 30 Kg/m2 37.1 (944)

45.5 (20) 0.26 Mean BMI +SD; Kg/m2 28.9 +6.9 30.0 +7.2 0.31 Regional Nodes Positive 12.5 (362)

19.2 (9) 0.17 Radiation therapy 67.4 (1918) 76.1 (35) 0.21 Total mastectomy

34.9 (1009) 38.3 (18) 0.63 Othera 65.1 (1884) 61.7 (29) Regional Nodes Exam >5 8.1 (234)

19.2 (9) Regional Nodes Exam 5 91.9 (2659) 80.8 (38) 0.006 MULTIVARIATE ANALYSIS, FACTORS SIGNIFICANTLY ASSOCIATED WITH INCREASE IN ARM VOLUME INCLUDED BMI 25 (P=.0236) ALND (P<.001)

[SLNB >5 nodes dissected] REGIONAL LYMPH NODE RADIATION (P=.0364) CELLULITIS (P<.001) Lifetime Risk Mostly in 2-3 year after surgery/RT ; Previously defined or clinical LE; we have better diagnostic tools today Medicare age group (>65), chance of developing LE is higher Its not clear why some people develop LE & others do not. How can clinical LE be diagnosed? Circumference

> 2 cm or more difference between limbs Volume > 200 mL difference, >10% volume difference D I A

G N O S I S Water displacement Circumference Bioelectrical impedance

Lymphoscintigraphy PDE: Indocyanine Green Lymphography MRI Lymphangiogram Tonometer Perometry SPY imaging system fluorescence properties of ICG Elastography: ultrasonographic technique PHOTO DYNAMIC EYE;

ICG Lymphography Uses IcG dye injected into web spaces and a hand held camera with laser fluorescence S1 S2 S3 S4 TA C TIL E MED IC AL |

12 MR lymphangiography MR lymphangiography provides important supplementary diagnostic information in patients with peripheral LE additional to LSG. Particularly in patients with focal dermal backflow and intended surgery, MR lymphangiography holds high potential for pre-surgical work-up Dermal backflow pattern indicating LE Soran A. et al.TJ Surg. 2017

Stage 0 (latent): Some damage; not yet apparent. Transport capacity is sufficient for the amount of lymph being removed; no LE. STAGE 1 (spontaneously reversible, Acute phase): "pitting edema reversible with elevation of the arm, upon waking in the morning, the limb(s)/affected area is normal or almost normal size. Stage 2 (spontaneously irreversible, Chronic phase): Spongy consistency, "non-pitting," Fibrosis found in Stage 2 LE marks the beginning of the hardening of the limbs and increasing size. Stage 3 (lymphostatic elephantiasis):Irreversibl, limb(s) is/are very large, tissue is hard (fibrotic) and unresponsive; consider undergoing reconstructive surgery called "debulking" at this stage. What happens if not treated ? + A cycle

of fibrosis, stasis protein accumulation progression and worsening of edema + Increased incidence of infection

+ Elephantiasis + Rare may develop in final stages complication of lymphangiosarcoma may occur Complications of LE +Repeated infections (bacterial and fungal) Accumulated lymph in the edematous arm provides a rich culture medium for bacteria Often require antibiotics +Lymphatic cysts on the surface of the skin

Reflux of lymph fluid +Non-healing wounds +Discomfort/pain +Functional impairment Parathesias Paralysis +Angiosarcoma [Stewart-Treves syndrome] Long-lasting LE (ie Stage 3) May develop in primary or secondary LE, Highly lethal +Hyperkeratosis Hypertrophy of the corenous layer of the skin Can LE be prevented? Lymphedema Progression Time and Age

49 % 36 % Volume Change <9% in 6 months progress to LE (36%) 1 year after surgery Comprehensive Lymphedema Program Prophylactic Strategy Early identification and intervention to postpone or inhibit LE progression to advanced stage, and avoid costly treatments by providing better QoL

High-risk group for lymphedema LN dissection (>5 nodes) RT to axilla, breast, chest wall, supra-infra clavicular area BMI>30 kg/m2 (>25) Age

More surgery: recurrence related Surgery to extremities (shoulder, arm, Hand) replacement) Genetic suspectibility Risk Prediction=post-mastectomy Why is early detection important?

Less clinical (S1-3) LE Less hardening (fibrosis) Decreased infection rate Improvement Joint aches Muscle pain and tightness More treatment options; much successful Increased Quality of life

Associated Cost Burden of LE Hospitalizations Outpatient visits Disability The matched cohort analysis demonstrated that the BCRL group had significantly higher medical costs and was twice as likely to have lymphangitis or cellulitis.

Start early PT for prevention Early PT may reduce risk of development of lymphedema after LND Education MLD; Self-Massage Scar Massage Ready made compression garments (15-20 mmHg) Exercise: stretching, range of motion, Weight training Review

necessary management techniques N=118 Early PT Clinical LE 7% Control 18% Clinical LE 25% BMJ 2010 ICG

Prevention 1. Obtain Baseline measurement (preoperative or 1st postop. visit after surgery) 2. L-Dex at 3-6 months after surgery (1st) 3. 3-6 month

interval 4. At least 5 year Life time??? MWH Study Study Group Control group Early Intervention Clinical LE

36.4% Soran A. Lymphat Res Biol. 2014. 9 times 32% Clinical LE 4.4% LE Evaluation Early Preop Ldex, Perometry ICG, MRL

Late Heaviness, Conventional Fullness measurements Swelling Other components of LE prevention program Nutritional consult Encouraging weight loss

Exercise; burn calories/fat Healthful eating, reducing calorie and fat intake BMI < 30 short term BMI

< 25 long term Patient Education Individual risk assessments (lifestyle, occupation) Possible risk factors Review of lymphatic function/anatomy Early warning signs Risk-reduction strategies What are the treatment options? Personalized Mechanical

interventions MLD EXERCISE, lifting Elevation Compression garments Pneumatic compression pumps Low level laser therapy

Thermal therapy Hyperbaric Oxygen Combination treatment modalities including IPC with CDT are both effective and tolerable modalities. IPC with SLD can be the choice of treatment in LE for applicability at home w/o interruption of regular life Summary + + + + + +

Common Comprehensive approach Education Monitoring (Disease and high-risk patients) Provide all diagnostic and treatment options Diagnose LE in early stage and intervene to prevent for severe LE is the priority

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