Presentation on theme: "Aspects of cancer related lymphoedema"— Presentation transcript:
1Aspects of cancer related lymphoedema Vaughan KeeleyDerby UKDublin, Sept 2014
2Aspects of cancer related lymphoedema What causes it?How can we detect it early?Can it be prevented?The problem of cellulitisLymphoedema in head and neck cancerSurgery for lymphoedema
3What causes lymphoedema after cancer treatment? Most studies have involved breast cancer related lymphoedema (BCRL)Ideas are changing
4How common is BCRL? Overall 21.4% 18.9% by 2yr 5.6% after sentinel node biopsy (SNB)19.9% after axillary node clearance (ANC)(Disipio et al 2013)BUT... difficulty with definitions and length of follow-up.
6Defining lymphoedemaDifficulty defining early lymphoedema
7Diagnostic criteria for BCRL 10% difference between limbs,200ml difference between limbs,2cm difference circumferential measurements10% change from baseline>3% change from baseline (sub-clinical)Patient reported symptoms (swelling, heaviness)
14But.... 6% women develop BCRL after SNB alone. 80% of women don’t develop BCRL after ANCBCRL takes months/years to developDistribution is not uniform
15Research observations: Local lymph flow when oedema present pumping pressure in lymphatics in established BCRL
16Study of breast cancer patients followed at 7m and 30m at 7m there was no impairment of lymph drainage if no swelling.those destined to develop lymphoedema had highest lymph flow in muscle + subcutislymph flow was also in the other (unoperated side) arm
17ConclusionsThis suggests a constitutional predisposition (both arms affected)A possible genetic effectThe high lymph flow may lead to damage to the lymph vessels over time and therefore the flow will reduce and swelling develop (delayed onset)
18Early detection and prevention It is evident that early mild lymphoedema is easier to treat than advanced lymphoedema with fat / fibrosisHow early can it be detected?Can it be prevented?
19Early detection 1 By limb volume measurement: - comparison with pre-op measurements- sensitive method eg Perometry- “subclinical” swelling (3% change?)- early intervention reduces swelling (and possibly prevents progression?) (Stout, 2008)
20Early detection 2 By bioimpedance spectroscopy - measures fluid changes in the tissues (the first stage of swelling)- evidence that this may detect lymphoedema months before a volume change is measured
21BEAMulti-frequency Bioimpedance in the Early Detection of Lymphoedema after Axillary Surgery- a multicentre study in UK examining whether BIS can detect BCRL before changes in limb volume (by Perometer) after ANC- aim – n=1100- recruitment to date = 1016 (Derby = 280)
22BEA – early resultsn=556Lymphoedema defined as 10% change in relative arm volume (RAVC)Incidence at 12m = 13.7%; at 24m = 25.0%Predictive factors: ER neg; no. of positive nodes; RAVC at 6m >= 5%-<10%
23Limitations of these methods At present, both Perometry and BIS do not measure hand swelling wellLocalised swelling may develop which is “diluted” by whole limb measurementsDifferential swelling - may be detectable with segmental BIS or Perometry; new methods being developed
24The benefit of pre-operative measurements May facilitate early detectionMay help identify high risk groups / consider introduction of preventative measures
25Prevention?Can the incidence of lymphoedema be reduced / condition prevented?- change in surgical / RT methods?- exercise?- MLD?- compression?- precautions incl weight management?
26Change in Surgery / RT?SNB associated with lower incidence of BCRL than ANCRT method changes - ? effect(NB more breast oedema since WLE + RT)
27Exercise Exercise programmes may help to reduce incidence (Box et al 2002; Torres Lacomba et al 2010)Changing advice on exercise of “at risk” arm.
28MLD (manual lymphatic drainage) Mixed evidence:- no effect (Devoogdt et al 2011)- positive effect (Zimmermann et al 2012)
29CompressionPossible effect of preventing progression of subclinical lymphoedema by wearing a compression sleeve for 1 month (Stout, 2008)Current UK study in progress: PLACE
30PLACEPrevention of Lymphoedema after Axillary Clearance by early External Compression.An RCT of the use of a compression garment for 1 year v standard care / precautions in women with a 4-8% increase in arm volume (Perometry) by 9 months post-ANCOutcome measure – lymphoedema in each group at 1 year and 18months after randomisationEarly treatment or prevention?
31Progress with PLACE Slow recruitment Fewer women than predicted reached threshold changes in RAVCCurrently expanding to those who have only had SNBLocal recruitment = 22 (total = approx 80)
32Genetic predisposition A number of candidate genesSamples being collected as part of BEA study.
33Precautionary measures Avoid injuries including cuts and abrasions, for example, wear gloves when gardeningUse a thimble when sewingUse an oven glove when cookingTake care when ironingAvoid tight clothing including tight bra straps
34Precautionary measures 2 Avoid irritating cosmetics/soapsAvoid sunburnAvoid insect bites/cat scratchesUse an electric razor for shavingAvoid obesity
35Precautionary measures 3 Avoid injections or venipuncture in the “at risk” armAvoid blood pressure measurement in the “at risk” armSeek medical advice if “at risk” arm becomes inflamed or swollen
36Breast lymphoedemaIncreasingly recognised following WLE and radiotherapyDifficult to measureClinical diagnosisTreatment – MLD / compression / taping etcMore research required.