Breast LE study: very common

kira66715 · March 2012

A new study from Andrea Cheville and others on the incidence of breast LE after treatment--very common:

http://www.ncbi.nlm.nih.gov/pubmed/22415476

Breast Cancer Res Treat. 2012 Mar 14. [Epub ahead of print]
A prospective study of breast lymphedema: frequency, symptoms, and quality of life.
Degnim AC, Miller J, Hoskin TL, Boughey JC, Loprinzi M, Thomsen K, Maloney S, Baddour LM, Cheville AL.
Source
Department of Surgery, Mayo Clinic and Mayo Foundation, 200 First Street SW, Rochester, MN, 55905, USA, degnim.amy@mayo.edu.

Abstract
Although lymphedema of the arm is a well-known complication of breast and axillary surgery, breast lymphedema has received scant attention. We sought to prospectively characterize breast lymphedema's incidence, associated symptoms, clinical course, and impact on quality of life. Subjects were enrolled prospectively from a consecutive sample of patients undergoing non-mastectomy breast procedures (excisional biopsy or wide local excision ± lymph node removal) and followed for signs and symptoms of lymphedema in the operated breast. Symptoms and distress were serially assessed with 11-point linear analog scales. Breast lymphedema was diagnosed independent of symptoms, based on the distribution and degree of edema and erythema. One hundred twenty-four women were followed for a median of 11 months, and breast lymphedema was diagnosed in 38 (31%) women. Breast lymphedema was more frequent after breast surgery with axillary node removal (49%) compared to breast surgery alone (0%), p < 0.0001. Breast lymphedema involved multiple quadrants in most women and was characterized by edema in 100% and erythema in 79%. Patients with breast lymphedema were significantly more likely than women without breast lymphedema to report symptoms of breast heaviness (65% vs 22%, p < 0.0001), redness (62% vs 29%, p = 0.0006), and swelling (59% vs 22%, p < 0.0001), but symptom-associated distress was low overall. Three of 32 breast lymphedema patients with clinical follow-up developed chronic edema. Breast lymphedema occurs in approximately one-half of women who undergo breast surgery with axillary node removal. The condition is characterized by diffuse skin edema and erythema as well as self-reported symptoms with a low level of distress.

carol57 · March 2012

Kira,

What are the differences between edema and lymphedema as used in this study? I'm confused, because the abstract seems to be saying that LE is diagnosed if there's some defined amount of edema, but only a few diagnosed with LE go on to have chronic edema. Huh? Something feels contradictory there. If only 3 of 32 patients diagnosed with breast LE went on to be diagnosed with chronic breast edema, does that mean most patients' swelling subsided? And if so, how did the researchers know it was LE and not transient postsurgical swelling? I'll bet I'm not the only one confused here.

Also, I had not before seen erythema noted as a symptom of LE. It's reddening of the skin, correct? I am surprised to see that 79% of patients diagnosed here with breast LE had this. I have truncal LE--side of my trunk, under the armpit. No redness ever. Is redness characteristic of breast LE but not elsewhere?

Lots to learn here! I hope my state online library has access to that journal so I can see the full article.

Carol

kira66715 · March 2012

Carol, I was a bit confused with that as well: I see a lot of redness with breast LE, and sometimes it gets confused with cellulitis, but I see women who are getting radiation. But, when the breast LE persists, I usually see just a thickened breast and some women have redness.

I didn't get the whole article. I'll look for it.

Kira

toomuch · March 2012

The wording of the abstract is very confusing but I'm glad that someone is looking at breast LE! I am 13 months post radiation and my breast LE has improved. It's no longer pitting but the swelling persist and my left breast does always have a slightly erythematous hue compared to the left. Okay this isn't scientific but it's what I've experienced! My RO and BS both said that they've seen breast LE improve for up to 2 years post rads/surgery. And if my memory is correct ( which is highly questionable some days!) Kathleen Francis was in agreement with that when I saw her last year. This study which followed women for only 11 months would seem to be reitterating that.

kira66715 · March 2012

I went to the on-line journal, and it's not up there yet! I'll keep an eye out for it.

Toomuch: in my experience, and in the "ask the expert" on bc.org, breast LE does tend to improve.

Racy · March 2012

Kira, thank you so much for posting this as it sounds exactly like what I have experienced. I have been unable to get a difinitive diagnosis and have been worried that my symptoms were more sinister. I have not found any other information that matches my symptoms so well. My symptoms do respond to antibiotics.

I guess there might be a causal relationship between breast LE and cellulitis?

With a correct diagnosis I can proceed to proactive treatment. I still don't understand why docs don't seem to know much about LE.

Kira, do you work in a medical field?

kira66715 · March 2012

Racy, I do work for a couple of rad oncs, and in medical education--so I have access to a medical school library.

Yes, there is definitely a causal relationship between breast LE and cellulitis: the same way arm LE and arm cellulitis are linked, and sometimes it's so hard to figure out when a pink swollen breast is infected.

I saw a follow up patient who had breast LE after treatment, and suddenly, a year out, had 2 bouts of breast cellulitis.

I can't believe the article isn't on the journal site yet, but it should show up soon. Let me know if you need a copy of it--we can exchange emails via pm.

Kira

It's there now: and this paragraph clarifies that the women developed breast LE, but most improved and 3 progressed:

Clinical status of breast lymphedema at last follow-up was improved in 23, stable in 4, ﬂuctuating in 6, progressive in 3, and unclear in 2. Overall, the median length of clinical follow-up subsequent to diagnosis of breast lymphedema was 11 months (range 0-37 months). The three cases that progressed experienced this outcome despite complying with recommended treatments of compression bra plus MLD (n = 2) and compression bra/MLD/chest compression wrap (n = 1).

Here's the conclusion:

In summary, breast lymphedema occurred commonly
after breast-conserving surgery with axillary node removal.
Breast lymphedema was characterized by diffuse mild
edema and erythema in more than one quadrant, and most
affected women have noticeable symptoms but a low level
of distress from this condition. However, improved
awareness of the condition of breast lymphedema may help
to avoid unnecessary use of antibiotics and to assist
patients with symptom management. Breast lymphedema
usually improves with time, and speciﬁc treatment inter-
ventions may be beneﬁcial although their efﬁcacy remains
unproven.

carol57 · March 2012

Kira, does this mean that the diagnostic criterion required the 'diffuse mild edema and erythema' to be in both breasts? (Otherwise, how can it be in more than one quadrant?)

And is 'breast' LE distinct from 'truncal' LE? So many women have written here that they have truncal, and very often we will read that their truncal is located on the side, under the axilla. That's where I have truncal swelling, in addition to the upper arm. It seems to me that all these observations of what seems to be persistant truncal means that 'truncal' does not tend to resolve like the researchers saw occur with 'breast' LE.

Just wondering. Breast LE / truncal LE not interchangeable terms?

Carol

Anonymous · March 2012

I thought the breast was considered part of the trunk. I'll br curious to learn if there is a difference or if it just refers to a specific area.

Racy · March 2012

Carol, I'm thinking it's just on the diseased breast. There are four quadrants on a breast. I think breast LE means the actual breast is affected. If the condition extends beyond the breast to the trunk it becomes truncal?

The condition that I have is definitely centred on the breast, with only occasional tightness under the arm and indentations from clothing extending towards the back. But the redness was only on the breast.

carol57 · March 2012

Racy, I just find it odd that there was a reference to two quadrants, when in LE lingo the body is divided into four quadrants that are the result of bisecting from neck to groin and from side to side at the waist. But neither does it make sense to require 'breast LE' to extend into that other upper body quadrant to meet 'breast LE' diagnostic criteria--so I think you must be correct.

Actually I read in one reference book I have that there are more 'quadrants' than four in the context of LE, but that we generalize and reference the primary four when talking about LE. Too confusing for words.

Carol

kira66715 · March 2012

When they wrote quadrants: they mean quadrants of the affected breast--they divided the breast into four quadrants and around the nipple.

They did not address truncal, and in my limited experience, working for the rad oncs, I see breast LE all the time--especially patients on treatment and more subtly as they follow up, but then I also see axillary LE (denied by the breast surgeon--I sent one woman with DCIS and no nodes removed with a beach ball under her arm for LE therapy, and they worked on her fibrosis and she's much better, and the surgeon dictated that I had diagnosed her with truncal LE and she responded to treatment, but on her exam she "notes swelling in the axila, no lymphedema"--how to deny reality.) And I see truncal LE in both patients with and without breast conservation.

So, they are just addressing breast LE. And kind of doing in response to the fact that many red breasts get treated as cellulitis when they are possibly just red from LE.

Kira

carol57 · March 2012

Crystal clear now! Thank you, Kira.

Racy · March 2012

I really think this is what I have had; it's not active at the moment. I have seen a physiotherapist who deals with LE twice in the past when I did not have active issues, and was shown the massage techniques of gently stroking lymph glands in the groin and under the arms and across the top of the breast. Is this the same as MLD?

And can I get any further benefit from seeing the physio again?

PS I am going to print the article and show it to my doctors, since they don't seem to be able to define a diagnosis for me, but this article makes it very clear.

carol57 · March 2012

Racy, That does indeed seem to be MLD. Your LE physiotherapist should have shown you a sequence of gentle strokes, including some that stimulate the nodes to clear them and others that enable you to gently nudge lymph across the superficial lymphatic vessels to the nodes you just cleared. The sequence and direction of your strokes should be tailored to where you have swelling and where you have healthy lymphatic vessels that can receive excess fluid. I think that until you have active issues to show the therapist, he/she is just guessing on how to craft a manual lymph drainage strategy that addresses your particular fluid location and blockages. Is it difficult to get into see the physio promptly, when you have swelling/redness?

I hope you 'll let us know how the doctors respond to seeing the article. Hopefully, they embrace the information and support your request for any additional treatment you need.

Carol

Breast LE study: very common

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