seromas and LE study

OMG, this is Mei Fu who is a director on our stepupspeakout site! She didn't tell me she was in San Antonio with this!

I developed a seroma and axillary web and it's what led to my LE.

When we were at the NLN conference, Jodi Winicour, the expert on AWS said that due to all the trauma to the axilla--especially with SNB where there is so much retraction, she doesn't want women lifting their arms above shoulder height for 10-14 days post op: the lymphatics are delicate, and if they're going to heal and re-form connections, they shouldn't be stretched.

She talked about women who were aggressively stretching post op and came in with big axillary seromas and AWS and developed LE--and she was describing me.

Sure wish I knew this stuff at the time...

I'll email her and get the abstract.

Kira

Man, I wish the info doctors gave us was consistent.  My BS told me he wanted me to be able to reach over the top of my head with my affected arm and touch the opposite ear after two weeks.  I couldn't do that for many weeks after my mastectomy and node removal and now I'm glad I didn't try harder.

I have Jodi's slides: and here was her slide on the critical healing for lymphatics and the desire to avoid additional traction through the axilla:

Lymphatic Regeneration
􏰀The stumps of the afferent or efferent
collectors of a removed node connect as
the result of proliferation of the
endothelium at the terminal portion of the
damaged vessel.
􏰀Regeneration of superficial vessels in
dogs takes 4 days and deep vessels in 8
days.

Her next slide was:

Protection vs. Movement-What's a Gal to do? 

So, it made sense to me, and I'd sure experienced the tons of webs and protracted seroma (my surgeon asked me what to do with it at the two week check, and I was tired and sore and told her to leave me alone, and it persisted for over 4 months until it was finally aspirated. Sure wish I'd had her aspirate it early--and wish she'd known what to do and didn't ask me to decide....)

Kira

Cookie, you're right, the study was in BMJ--and there was a sub-set of women who developed axillary web syndrome who developed LE at a high rate. I'm not sure if the study details what the PT involved--I believe it was LE therapy.

Found the abstract: They did PT in the first month after ALND

ABSTRACT
Objective To determine the effectiveness of early
physiotherapy in reducing the risk of secondary
lymphoedema after surgery for breast cancer.
Design Randomised, single blinded, clinical trial.
Setting University hospital in Alcalá de Henares, Madrid,
Spain.
Participants 120 women who had breast surgery involving
dissection of axillary lymph nodes between May 2005 and
June 2007.
Intervention The early physiotherapy group was treated
by a physiotherapist with a physiotherapy programme
including manual lymph drainage, massage of scar
tissue, and progressive active and action assisted
shoulder exercises. This group also received an
educational strategy. The control group received the
educational strategy only.
Main outcome measure Incidence of clinically significant
secondary lymphoedema (>2 cm increase in arm
circumference measured at two adjacent points
compared with the non-affected arm).
Results 116 women completed the one year follow-up. Of
these, 18 developed secondary lymphoedema (16%): 14
in the control group (25%) and four in the intervention
group (7%). The difference was significant (P=0.01); risk
ratio 0.28 (95% confidence interval 0.10 to 0.79). A
survival analysis showed a significant difference, with
secondary lymphoedema being diagnosed four times
earlier in the control group than in the intervention group
(intervention/control, hazard ratio 0.26, 95% confidence
interval 0.09 to 0.79).
Conclusion Early physiotherapy could be an effective
intervention in the prevention of secondary lymphoedema
in women for at least one year after surgery for breast
cancer involving dissection of axillary lymph nodes.
Trial registration Current controlled 

Here's the paragraph re: AWS

We also found that 12 of the 18 women who developed
secondary lymphoedema had axillary web syndrome
during the second and third week after surgery.
The axillary web syndrome is a known but poorly studied
complication of surgery. No study has
shown any link between the axillary web syndrome
and the onset of secondary lymphoedema. We and
others suggest that the axillary web syndrome
may be a sign of injury to the lymphatic system and it
could produce a lymphatic overload as a result of failure
of the lymphatic system. This overload, together
with other factors, could be responsible for the onset
of secondary lymphoedema. 

Also, this was their theory:

Recently, a study to develop an animal model of postsurgical
lymphoedema reported that after nodal excisions
the limbs became progressively more
oedematous up to three days after node dissection
and that the swelling decreased but had not resolved
16 weeks after surgery.58 Taking this into account and
since the basic rule is that all oedemas result from an
imbalance between filtration and resorption (tissue
drainage), the implementation of a measure to restore
this balance during the period of higher filtration
should prevent or delay the onset of secondary
lymphoedema. Our study included manual lymph
drainage, which is a special method involving gentle
massage to improve the lymph circulation, especially
subcutaneous circulation, to stimulate the initial lymphatics,
and to stretch the lymph vessels, consequently
improving the removal of interstitial fluid. Manual
lymph drainage encourages and improves resorption
without increasing filtration.34 59 It has been shown to
be effective in the treatment of lymphoedema because
it improves the removal of fluid from interstitial
space.32 34 59 60 We therefore think that the implementation
of manual lymph drainage after surgery for breast
cancer in the early physiotherapy group could have
contributed to the better results in that group. This,
together with early physiotherapy for other effects of
breast cancer surgery, and related to the onset of secondary
lymphoedema,18 20 21 23 24 could explain the
effectiveness of early physiotherapy in the prevention
of secondary lymphoedema in women who have had
surgery for breast cancer with axillary lymph node dissection-
at least during the first year after surgery.
 

Kira

cookiegal, thanks for posting that link. I saw a press release about the article in my in-box today, and I'm glad someone posted it here.  It is very relevant!

Odds and ends:

1) alex56 said:  "My BS told me he wanted me to be able to reach over the top of my head with my affected arm and touch the opposite ear after two weeks." Yeah, what's with that?

My BS told me on the day I left the hospital (left mast/SNB) that she did not want me reaching above my shoulder until after my drains were both out, which took 10 days.  Four days after that, I went back to her to have a seroma aspirated (more about that in a minute), and she was "surprised" that I could not raise my arm straight above my head so she could do the aspiration. "But, you told me not to!", I protested. The point was that the messages I'd been getting were not consistent.  She gave me suggestions about stretching exercises, and I started reading about post-mastectomy PT and doing it on my own.  Was that a mistake?  I did not have the range-of-motion I should have had at that point, so PT seemed appropriate.

2) Things went okay after that, until I developed axillary web syndrome about 3 weeks after surgery. I went back to my BS, who noted that I still did not have acceptable range of motion. So, she referred me to a PT/LE therapist. The therapist was booked for the next 4 weeks, and by the time she could see me the AWS was gone. I had a good (2-hour) orientation/educational visit with her, though.

3) Everything went well until 3 weeks after my last chemo infusion, which was ... wait for it:  Taxotere & Cytoxan!  (Yes, I do think there's an association between the taxanes and risk of LE.)  The AWS returned with a vengeance (2 distinct cords, one running across my inner elbow to my wrist).  I also developed swelling in my thumb web, index finger, back of my hand, wrist, and forearm.  I went back to my BS, and she sent me back to the PT/LE therapist.  She said I had "Stage 0" LE because it was not measurable with the usual techniques but was clearly visible.  She sent me for a sleeve and gauntlet, taught me how to wrap my arm, taught me MLD, and provided me with 3 therapy sessions (including some terrific upper-body exercises).

So, my story was mast/SNB --> seroma --> axillary web syndrome --> Taxotere chemo --> mild lymphedema.  I will be interested to hear what the physiologists say about that link between seromas and LE.

otter

I had a seroma that I got drained in a walk-in clinic so my surgeon never saw it. But, it seemed like I still had too much tissue left, so I did go see him and he agreed to an incision-revision. Well....after the surgery at my post-op visit he was absolutely STUNNED at how much "tissue" seemed to be there still. He swore he took out a good chunk. He never acknowledged LE and didn't "believe" in it. It was my onc that caught my truncal LE...sigh. I always wonder if I hadn't gone for that incision-revision but was treated for LE instead.....

 cookiegal, you just described me to a T.  Add in the neuropathy too.  That's how I feel, the time and effort that goes into dealing with the disability makes it hard to live life to the fullest for sure

SleeveNinja,

Interesting questions.  I was wondering similarly if the aspiration I had might have been more of a problem than the small-ish seroma.  I also had tight strands that sometimes popped (without pain) when I was doing my stretches some weeks out from surgery.  I hadn't heard of cording until I came here a year after my surgery.  And I had the pulley and rope, from my PT.  I had so much nerve pain from the ALND that I couldn't do the exercises the surgeon gave me.  I wonder if that was a good thing now.   I ended up with 3 months of PT because of the nerve damage, and I do have some limited range of motion on left side, due, I have assumed, to some scar tissue or poor surgical technique on that side.  

At the end of the day, however, I am pretty sure I will never know how this could have gone better, but I sure wish it had, and I certainly wish someone would make it better for the ones who come after me!

Dawn 

Hmmmm... I didn't read through all the posts, or the whole study for that matter... but I DID have a seroma after my mastectomy. Interesting, interesting.

Got the abstract from Mei:

Title: Seroma Formation is Associated with Lymphedema Related Symptoms
Authors:
Mei R. Fu, PhD, RN, ACNS-BC; Assistant Professor; College of Nursing, New Yrok Univertsity, New York, US
Amber A. Guth, MD, FACS, Department of Surgery, New York University Clinical Cancer Center, New York University School of Medicine, New York, NY
Elenice Dias Ribeiro de Paula Lima, RN, PhD, Federal University of Minas Gerais, Brazil
Francis Cartwright, PhD, RN, Director of Nursing, New York University Clinical Cancer Center, New York University School of Medicine, New York, NY
Deborah Axelrod, MD, FACS, Department of Surgery, New York University Clinical Cancer Center, New York University School of Medicine, New York, NY

Background. Seroma formation or accumulation of serous fluid is one of the most common wound complications following breast cancer surgery, occurring from 30% as evidenced by needle aspiration to 85% by ultrasound in women following breast cancer surgery. Seroma formation has been speculated as a resultant of lymphatic fluid collection or acute inflammatory exudates in response to surgical trauma and acute phase of wound healing. Seroma usually leads to prolonged wound healing, tissue inflammation and subsequent fibrosis and necrosis, it has been hypothesized that seroma formation is one of the main risk factors for post-breast cancer lymphedema. Lymphedema, a syndrome of abnormal swelling and multiple distressing symptoms, exerts great negative impact on breast cancer survivors' quality of life. Understanding the relationship of seroma with lymphedema and related symptoms may help to reduce the risk of lymphedema through effective management of seroma.

Purpose. To explore the relationship of seroma with lymphedema-related symptoms.

Materials and Methods. Data were collected from 135 breast cancer survivors using a Demographic and Medical Information interview tool, clinical assessment, and Lymphedema and Breast Cancer Questionnaire for lymphedema related symptoms. Data analysis included descriptive statistics, t-tests, Chi-square, Fisher's exact test, and correlation coefficients.

Discussions. Thirty-five patients (26%) developed seroma following breast cancer surgery as evidenced by needle aspiration. Locations of seroma formation included axilla, breast, and upper chest. Of the 35 women, 33 (94%) had measurable lymphedema; clinical assessment revealed that 26 of the 35 women had severe lymphedema and the rest of 9 patients had mild and moderate lymphedema. Age, type of surgery, number of lymph nodes removed and positive axillary lymph nodes were not correlated to seroma. Body mass index (BMI) was significantly correlated to seroma (r = .172, p = .04).

Pearson correlations showed seroma formation was significant correlated with symptom cluster of lymphedema (swelling, heaviness, firmness/tightness, numbness, and stiffness; r = .224, p = .009) and inflammation (redness, higher temperature, and tenderness; r = .287, p = .001). Significantly, more women with seroma experienced more lymphedema related symptoms. Having seroma, lymph nodes removed and radiotherapy together accounted for 10% of lymphedema-related symptoms (R2 = .10, p = .003). Estimated relative risk for the women who had seroma in developing lymphedema was approximately 3 times more than those who did not (p = .00).

Implications: It is important to assess and manage seroma formation. Evaluating symptom clusters of inflammation and lymphedema may be one of the cost-effect strategies to detect subclinical seroma to ensure timely interventions to prevent excessive fluid production and build-up. Current routine clinical management of seroma mainly uses needle aspiration. Further research should focus on other effective strategies to minimize seroma formation, such as strategies of promoting fluid drain and prevention of inflammation.

Wish I knew this back when I had my seroma that wasn't drained. It makes a case for ultrasounding women to pick up subcliinical seromas, and trying to prevent them and treating them when they occur.

Kira

Got another reference, from the Vodder school--they used kinesio tape on 8 women to reduce seroma--whether or not that is the best treatment, I found the information about the inflammation caused by seroma to be interesting, and consistent with what we've all posted:

http://www.vodderschool.com/current_articles

I actually sent the SABC abstract to my (former) surgeon as an FYI. Never hurts to protect the women who come behind us....

Kira

Sharon, for me, it led to a pdf of the article--

Here's another link to their blog--the article is in Lymphology, which normally requires a subscription.

http://vodderschool.blogspot.com/

Kira

It led me to the pdf too Kira but I couldn't open anything after that.  I know it's some update on my puter that I've not updated.  I have no idea how to fix it.

Then it's bad to drain it? Or the excess still has to be drained even though it's supposed to be there? What is this kinesio tape?

Wow! That stuff sounds amazing! And they even have latex-free. Where do you get it and is it expensive? I guess I'd have to have a professional put it on....