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C ancer RLE RISK FACTORS

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.

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C ancer RLE RISK FACTORS

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  1. Lymphedema and breast cancer TherapyImpact of identifying high-risk patients and early intervention Atilla Soran, MD, MPH, FNCBC, FACSProfessor of Clinical SurgeryBreast Surgical OncologistDirector, Comprehensive Lymphedema ProgramMagee-Womens Hospital of UPMC

  2. WHAT IS LYMPHEDEMA? Swelling: protein rich fluid accumulationCauses of LE ; removal or damage of the LN SurgeryRT CVIInfectionTraumaMuscle strainGenetic defect in the lymphatic system

  3. CANCER TREATMENT FACTORS LND GREATER NUMBER OF LYMPH NODES DISSECTED Extensive surgery RT CT HIGHER STAGE OF DISEASE POSTOPERATIVE INFECTION DEMOGRAPHIC FACTORS HAND DOMINANCE AGING EDUCATION GENETIC DISPOSITION CancerRLE 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

  4. MWH Experience ( 36th Miami Breast Cancer Conference-3/19 • Other includes segmental mastectomy/ lumpectomy/ reexcision

  5. 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)

  6. 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 It’s not clear why some people develop LE & others do not.

  7. How can clinical LE be diagnosed? Circumference • > 2 cm or more difference between limbs Volume • > 200 mL difference, • >10% volume difference

  8. DIAGNOSIS • Water displacement • Circumference • Bioelectrical impedance • Lymphoscintigraphy • PDE: Indocyanine Green Lymphography • MRI Lymphangiogram Tonometer Perometry SPY™ imaging system fluorescence properties of ICG Elastography: ultrasonographic technique

  9. PHOTO DYNAMIC EYE; ICG Lymphography S1 S2 S3 S4 Uses IcG dye injected into web spaces and a hand held camera with laser fluorescence

  10. TACTILE MEDICAL |

  11. 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

  12.  Soran A. et al.TJ Surg. 2017

  13. 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.

  14. What happens if not treated ? • A cycle of fibrosis, • stasis • protein accumulation • progression and worsening of edema • Increased incidence of infection • Elephantiasis may develop in final stages • Rare complication of lymphangiosarcoma may occur

  15. 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

  16. Can LE be prevented? Lymphedema Progression Time and Age 49 % 36 %

  17. Volume Change <9% in 6 months progress to LE (36%) 1 year after surgery

  18. Comprehensive Lymphedema ProgramProphylactic StrategyEarly identification and intervention to postpone or inhibit LE progression to advanced stage, and avoid costly treatments by providing better QoL

  19. 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

  20. Risk Prediction=post-mastectomy

  21. 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

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

  23. 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

  24. BMJ 2010 N=118 Early PT Control 18% Clinical LE 7% Clinical LE 25%

  25. ICG Prevention

  26. 1.Obtain Baseline measurement (pre-operative or 1st postop. visit after surgery) • L-Dex at 3-6 months after surgery (1st) • 3-6 month interval 4. At least 5 year… Life time???

  27. MWH Study Study Group Control group Early Intervention Clinical LE 36.4% Clinical LE 4.4% 9 times 32% Soran A. Lymphat Res Biol. 2014.

  28. LE Evaluation EarlyLate Preop Heaviness, Conventional Swelling Ldex, Perometry Fullness measurements ICG, MRL

  29. 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

  30. 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

  31. 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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