Reducing
Lymphedema -- Research Summary
Reducing Lymphedema
BOSTON, MA
(Ivanhoe Newswire) -- Great news! Doctors say cure rates are getting better for
breast
cancer, but many women are left with unwanted, sometimes
devastating side effects. We’ll show you what’
s making a big
difference in the lives of survivors.
When Katie Brophy learned she had
breast cancer, she wasn’t surprised.
“I sort of expected it, obviously
when you have a lump, you just assume,” Katie Brophy, told Ivanhoe.
A
lumpectomy and radiation took care of her cancer, but left her with the risk of
lymphedema , a side effect
of treatment that causes fluid build-up
in the limbs. as an interior designer, that worried her.
“I’m physical.
I paint walls. I wallpaper, refinish wood. The last thing you need to do is
have an impaired
arm,” Katie said.
Mayo clinic doctor Andrea
Cheville says radiation may destroy arm-draining lymph nodes. Once they’re
damaged, the risk of lymphedema rises and so does the risk of
infection.
“It’s unattractive and so I think socially it’s a very
difficult condition for people,” Andrea Cheville, M.D.,
MSCE, from
the Mayo Clinic physical medicine and rehabilitation, said. “Our best hope is
to prevent
people from getting it.”
To do that, she’s
testing a new technique that combines CT scans with Spect-imaging. That
powerful combo
pinpoints exact locations of critical lymph
nodes.
“The physicians who are planning a woman’s radiation can know
exactly where those critical nodes are and
avoid them, block them
from the radiation field, ”Dr. Cheville said.
Studies show it reduces
the number of critical lymph nodes that receive harmful radiation by more than
55
percent.
“We treated 30 women. None of those women have
developed lymphedema,” Dr. Cheville said.
Katie was one of those
women.
“At the moment, I’m very pleased with the result. Two years have
passed. I have no symptoms,” Katie said.
Doctor Cheville says one big
advantage of this new approach is many medical centers already have both of
these imaging technologies. Training physicians to fuse the two
techniques for this purpose may be all that’s
needed to help women
reduce their risk of lymphedema
BACKGROUND: Between 5 percent
and 40 percent of women are estimated to experience some form of
lymphedema after breast cancer surgery; however, the condition is often
overlooked or misdiagnosed.
Lymphedema occurs when the lymph system
is damaged or blocked. It can cause fluid buildup and swelling
and
usually affects an arm or a leg, but it can affect other parts of the body.
Lymph fluid, tumors, lymph
vessels and lymph nodes all can play a
part in lymphedema. (SOURCES: www.breastcancer.org, www.
cancer.gov)
CAUSES AND SYMPTOMS: Lymphedema can be either
primary or secondary. Primary lymphedema is
caused by abnormal
development and can occur at birth or develop later in life. Secondary
lymphedema is
caused by damage to the lymph system due to
infection, injury, cancer, scar tissue, or radiation therapy.
People
can be at risk of developing lymphedema if they are obese, smoke heavily, have
diabetes or have
had a mastectomy or previous surgery to the armpit
area. Along with swelling, people with lymphedema may
experience a
feeling of heaviness or tightness in the arm or leg. They may also feel aching
or discomfort and
possibly hardening of the skin around the
affected area.
(SOURCES: www.cancer.gov, www.breastcancer.org and Mayo
Clinic)
NEW PREVENTION TECHNIQUES: Using single photon emission computed
tomography (SPECT)
along with computerized tomography (CT) scans,
doctors may be able to offer substantial protection against
lymphedema. Although a person may have as many as 62 lymph nodes under
the arm, only a few are
responsible for the removal of fluids from
the arm. The SPECT-CT technique works best for patients who
do not
require radiation targeting any remaining lymph nodes. The risk of developing
lymphedema may be as
much as 50 percent without taking measures to
preserve the function of a person’s lymphatic system.
Because
lymphedema can occur years after a surgery, patients will continue to be
monitored by their
physicians for signs of lymphedema. Currently,
there are two treatment plans for each patient: a standard
plan and
one adapted for lymph node sparing based on the SPECT-CT scans. (SOURCE: Mayo
Clinic)
Reducing Lymphedema -- In Depth Doctor's Interview
Andrea
Cheville, MD, MSCE, from the Mayo Clinic -- Physical Medicine and
Rehabilitation, talks about a
new way to potentially prevent
lymphedema
Tell me what lymphedema is.
Dr. Cheville: Lymphedema is a
potentially devastating condition that’s characterized by enlargement of a
body part because of the build-up of protein rich fluid. And it’s
unfortunate for many reasons it places
patients at risk of bad
medical events, recurrent infections, un-healing wounds. But beyond that it
changes
the way they look, it distorts them, you know you have a
very big head or a very big arm. It’s unattractive
and so I think
socially it’s a very difficult condition for people. It’s also uncomfortable
and currently we
cannot cure it. We can control it through a
collection of burdensome and very time-consuming self
management
activities. Which are wrapping and wearing compression garments which patients
never like it’s
always difficult for them. So right now and our best
hope is really to prevent people from getting it.
Once you get it are
you always going to have it?
Dr. Cheville: Yes.
So even if you
can control it you still have it and you have to keep doing the
control?
Dr. Cheville: The way I explain it to patients sometimes is if
you have a little town that gets bigger and you
don’t expand its
sewage system and so every time you have a heavy rain it has a potential to
flood. So you
just have more production than the system can handle
and so you always have the potential for overload.
We have lots of
therapeutic tricks we do to even that out so that patients can handle, can
remove the
amount of swelling, fluid that their body brings to
their tissue. But again it’s not easy for them. There’s no pill,
there’s no surgical procedure that can make this go away.
And
why does it occur?
Dr. Cheville: Well, so we have two sets of pipes, you
can kind of think of it as plumbing, that the arteries
bring lots of
fluid, an astounding amount of fluid into your body tissues every minute of the
day. And the way
that fluid gets out most of it is through the
veins but there’s a second set of pipes that most of us don’t know
about until you get lymphedema and when they stop working. But what the
lymphatics are responsible for
doing is removing about five percent
of the fluid that comes in to tissue during the day but they’re really,
really good at carrying out large solid waste. That is what they are
uniquely designed to do so bacteria, large
fats, large proteins
that’s really the specialty of the lymphatic system. And when patients undergo
cancer
treatment, in fact in the developed world certainly in the
United States that’s the number one cause of
lymphedema. We injure
the system by removing lymph nodes or irradiating lymph nodes in order to stage
a
cancer or to treat a cancer.
So women with breast cancer
are prime candidates to get this right?
Dr. Cheville:
Absolutely.
Is that because of where you’re treating because if you have
pancreatic cancer you’re not near the lymph
nodes in the arms, is
it the area that you’re treating?
Dr. Cheville: Yeah, that’s a part of
it. So you ask the great question of why once you take out those lymph
nodes you’ve damaged the system, you’ve interrupted the pipe, the
plumbing so in essence it’s a plumbing
issue. But we do we focus on
the fluid but what we really worry about is all that big waste material that it
can
build up in the tissue and cause a lot of problems. And so with
breast cancer treatment is changing so we are
less aggressive with
our treatment. We used to always take every last lymph node out of a woman’s
armpit.
Now we don’t we do a special technique to try and identify
the nodes that might have cancer. We take
those out first see if
they have any tumor cells and if they don’t we leave the rest of the nodes. So
some of
the good news is that there’s less lymphedema now in women
with breast cancer. But for those women who
do have all the nodes
in their armpit taken out they are at high risk of developing lymphedema in the
arm on
the same side but also in their trunk the front and back of
their upper trunk as well as their breast if they’ve
elected for
conservative treatment.
Are there some lymph nodes that are more
critical for draining fluids than other?
Dr. Cheville: They all drain
fluid. There’s a lot that we don’t understand about the lymphatic system. There
are lots of layers, eventually lymph is going to be dumped back in
to the bloodstream and as I said some of
that solid material that
the body picked up is bacteria and the last thing the body wants to do is put
bacteria
in the bloodstream. So what happens to the lymph is it
gets purified time and time again in lymph nodes and
certain lymph
nodes are kind of responsible for certain drainage territories. So you have
certain nodes that
drain the breast and certain nodes that drain
the arm. And from what we’ve found they’re usually one to at
most
three nodes that are kind of the first order that receive most of the lymph
from the breast. Other lymph
nodes are going to get that lymph
later to purify it again and again to make absolutely sure that we don’t
introduce something harmful into the blood stream.
So people get
this because you’re removing the nodes or irradiating the area, you’re not
exactly meaning to
irradiate those lymph nodes?
Dr.
Cheville: Exactly. Well sometime we do. If we think that a woman is at very
high risk of the cancer
coming back then we have to. The priority
is saving her life and avoiding a breast cancer related death. So
we absolutely have to irradiate the nodes in her armpit and often we
irradiate the nodes at the base of her
neck as well to sterilize
the field of any tumors cells. But for women who we don’t think they need
radiation
to their lymph nodes we did what’s called a sentinel node
biopsy, we took a few nodes we looked at them
we don’t think she
has any cancer in her lymph nodes then we want to spare them by all means.
Because
that reduces her risk of ultimately of developing incurable
lymphedema. What we found in our research was
that women who were
just receiving radiation to the breast, they’ve decided to keep their breast
and not
have the mastectomy so there we’re irradiating the breast to
get rid of any tumor cells. What we found is
about forty percent of
the time even though we’re not targeting them the nodes that drain the arm are
receiving potentially harmful doses of radiation.
Tell me
what you’re studying because prevention is what you’re going for there is no
cure.
Dr. Cheville: Our hope is to do everything we can while a woman
goes through primary breast cancer
treatment to reduce her risk of
ever developing lymphedema. We’ve earned the luxury in cancer treatment
now about worrying about patients quality of life. We’ve gotten very
good at curing people particularly
patients with early stage breast
cancer and now we’re able to broaden our focus and start to refine our
treatments so that they do the least damage possible to normal tissues.
And that’s really the theme of my
research. We know that as I said
surgically removing the lymph nodes and radiating the lymph nodes is what
injures the system and increases a woman’s likelihood of developing
lymphedema. The surgeons have done
a fabulous job of steadily
reducing the unnecessary surgical damage but we haven’t done much to reduce a
woman’s radiation exposure. So we’ve developed a technique where we
identify the lymph nodes. We go
for arm drainage because that’s
where most women will develop bad lymphedema. We worry about the
breast, the trunk but it turns out that the body is very good at
developing other pathways to drain the lymph
but they can’t do that
in the arm because it’s all got to get out of the arm. So our work is focused
on
protecting that are the first order recipients of lymph from the
arm.
So how many of the lymph nodes in the arm area are you removing or
are you trying to protect all of them?
Are there critical ones that
you don’t want to remove?
Dr. Cheville: The way we identify these lymph
nodes is we inject a very small amount of radioactive tracer in
the
back of the hand and the inner part just inside the elbow. And it’s very safe
this is a very routine
procedure, it’s something we do thousands of
times a day in the United States. But we’re using this
technique in
a slightly different way. We introduce the tracer just below the skin that
causes a bee sting that
goes away quickly and then that tracer
because it’s linked to a big molecule, a big solid material so the
lymphatics take that up and they transport it back to the critical
nodes that are draining the arm. And usually
we find that’s about
one to three and those are the nodes we want to spare. And almost always
there’s one
node that takes up a lot more tracer than the
other.
So is there an average in a woman, ten nodes or three
nodes?
Dr. Cheville: If a woman has only undergone what we call a
sentinel lymph node biopsy, and to identify the
nodes that are
draining the breast we use exactly the same technique, we put the same
radiolabel tracer in
her breast and we identify the nodes that are
draining the breast, look at those for cancer cells and as I
mentioned if they’re clean we leave the rest of the nodes. So in a
woman who has only undergone that
procedure her sentinel node,
which is the name of the nodes that light up when we inject the breast, if the
sentinel node is negative and we inject the arm usually we see on
average two point four nodes. However if
a woman has undergone what
we call a completion axillary dissection, that’s when the sentinel node was
positive, so we have to take most of the remaining nodes in her armpit
and we inject her arm we see from
between five and seven lymph
nodes. And what that reflects is that the lymph is trying to get back. It’s
trying
very hard to make its way back through the system but the big
channel is gone because the nodes that
usually are the first
recipients of the lymph have been surgically removed. So that lymph is going to
all kinds
of different nodes trying to work its way back and forge
new drainage pathways.
So what is the imaging technique called that
you’re using?
Dr. Cheville: SPECT.
Can you tell me what it stands
for?
Dr. Cheville: Single photonic emission computed
tomography.
So is it called the SPECT CT?
Dr. Cheville: Yeah,
SPECT stands for single photon emission computed tomography and it combines two
techniques. We have what are called Gama cameras that pick up
radioactivity so they do a fabulous job of
identifying where that
tracer that we injected into a woman’s arm where that goes and which nodes now
have the tracer. But it doesn’t tell us, if we have a picture we
just see black dots which isn’t very
informative. A CAT scan gives
us a lot of anatomic detail and when we put those two scans together we can
see exactly where those critical nodes are located in the
body.
Is the imaging technique new or is using it in this way
new?
Dr. Cheville: Using it in this way is new.
So hospitals
across the country use this technique in other imaging needs?
Dr.
Cheville: That’s one of the strengths of this technique is that the technology
is widely available in most
medical centers.
So it’s really
the combining of the two that’s this new approach, is it something that people
would have to go
through training or could most labs do
it?
Dr. Cheville: Most labs, the tricky thing it turns out is not
acquiring the images. What we do, the goal of the
research is to
take the SPECT CT and to fuse it with the CAT scans that are used in radiation
planning. And
so we merge those images and that way the physicians
that are planning a woman’s radiation can know
exactly where those
critical nodes are and avoid them, block them from the radiation
field.
How are they blocked?
Dr. Cheville: It’s actually very
simple. They are able, now it’s computerized so they’re able to change the
field a little bit.
It’s so precise that they can just move it
over, nothing has to be laid over or anything like that?
Dr. Cheville:
No really it’s done on a computer.
What are the results of your study,
what have you seen?
Dr. Cheville: What we found and it exceeded our
wildest hopes we’ve been able to reduce the amount of
incidental
radiation. This is radiation that’s not therapeutic it’s not needed to reduce a
woman’s risk of
cancer, it’s the nodes are getting radiation they
don’t need. We’ve been able to reduce the number of nodes
getting
damaging doses by about fifty percent.
What were you thinking when you
saw the results?
Dr. Cheville: I was really delighted. It’s not a huge
deal for a woman to go through this, you know this scan.
It’s a
one-time deal and it may protect her for the rest. If we can incorporate this
technique it could protect
her from developing an incurable and
very, very difficult condition.
Reducing the incidental level of
radiation how does that translate in to the number of causes you’ve seen of
women with lymphedema? Have you see a drop in cases here?
Dr.
Cheville: We treated thirty women none of those women have developed
lymphedema. We did not have
a control group in this study so that’s
the next step is to get an estimate of lymphedema. Because protecting
the
nodes is nice but what we really want to do is eliminate lymphedema and so the
next step is a
randomized controlled trial.
Is that
something you’re working on now?
Dr. Cheville: I’m working on getting
funding.
This is something that could be adopted by hospitals across the
country even though they could start doing
this now or you need to
do the randomized control trial to make sure this is worth it and really
meaningful?
Dr. Cheville: What really supports what we do in Western
medicine is the strength of the evidence that
supports it. And so we
do a lot of things that don’t have a strong evidence base I feel very
passionately that
we have good evidence. And so my colleagues and
co-investigators want very much to just offer this to
women, It’s
kind of a why would you not. Why would you not there’s no harm, really SPECT is
a very safe
technique we’ve never had any adverse events from the
injection so their question is why would you not. If
we have the
opportunity to even spare one patient from lymphedema it’s not prohibitively
expensive, it’s not
challenging for patients. But as a scientist I
feel we really do have to do this right.
Let’s say you have this
randomized study and what you see then is what you see now what would this do
for
women, what kind of impact would this have?
Dr. Cheville:
That’s a tricky question to answer because in my clinical work and I treat
lymphedema but I
became passionate about this because I experience
firsthand how frustrated women become trying to
control this
condition indefinitely. And so over time my research interest came to focus on
prevention
because I think that’s our best shot at really helping
them. So in my clinical work I divide women in to,
breast cancer
survivors, into three categories. Those who have had a sentinel lymph node
biopsy only and
their risk of lymphedema is relatively low, it’s
about seven to ten percent. Numbers have been published up
to
seventeen percent and in part it reflects that we haven’t followed these women
prospectively a long time.
So actually if in ten years we may find a
higher incidence of lymphedema in the group but they are at the
least risk. Then you take women who are in the middle group they have
had all of their or most of their
lymph nodes in their armpits
removed but they didn’t need radiation to the armpit. I think those are the
women who will really benefit from this technique because their risk
may approach forty percent, their
lifetime risk of developing
lymphedema. And I think that’s the group that we can really help with this.
Then
the third group is those women who present with later stage
disease and we simply have to treat them very
aggressively. We have
to radiate all the nodes to protect them from recurrent cancer. And there are
other
strategies that we’re looking at for that group of women. But
it’s really that middle group.
And so for that group how would this
affect their lives, how would this change their future if this
works?
Dr. Cheville: I think in two important ways, one there’s a lot of
peace of mind of not being at risk for
lymphedema. Because
lymphedema is harmful not just having it, that’s a kind of indefinite burden
that
plagues women. It affects their work performance, their
psychological well being, their familial rolls, it really
undermines every quality of life domain. So avoiding it is critical but
even knowing that you’re at risk is very
distressing for women.
They are frightened, we don’t always do a great job of educating them in the
means
that they can reduce their risk. So I think giving women
peace of mind even if they never develop
lymphedema that their risk
has been substantially reduced is a very valuable contribution.
People
that do radiation must hear that a lot, that I’m scared of getting lymphedema
because people have
had friends or family that had it.
Dr.
Cheville: The internet, the internet is a blessing and a curse but you can
certainly very quickly call up
some gruesome pictures of lymphedema
with a brief search. And it frightens women
terribly.
Dana Wirth Sparks
Mayo Clinic Department of
Public Affairs
(507) 538-0844
[email protected]
http://www.mayoclinic.org/medical-edge/
http://newsblog.mayoclinic.org
http://socialmedia.mayoclinic.org/
Lymphedema -- Research Summary
Reducing Lymphedema
BOSTON, MA
(Ivanhoe Newswire) -- Great news! Doctors say cure rates are getting better for
breast
cancer, but many women are left with unwanted, sometimes
devastating side effects. We’ll show you what’
s making a big
difference in the lives of survivors.
When Katie Brophy learned she had
breast cancer, she wasn’t surprised.
“I sort of expected it, obviously
when you have a lump, you just assume,” Katie Brophy, told Ivanhoe.
A
lumpectomy and radiation took care of her cancer, but left her with the risk of
lymphedema , a side effect
of treatment that causes fluid build-up
in the limbs. as an interior designer, that worried her.
“I’m physical.
I paint walls. I wallpaper, refinish wood. The last thing you need to do is
have an impaired
arm,” Katie said.
Mayo clinic doctor Andrea
Cheville says radiation may destroy arm-draining lymph nodes. Once they’re
damaged, the risk of lymphedema rises and so does the risk of
infection.
“It’s unattractive and so I think socially it’s a very
difficult condition for people,” Andrea Cheville, M.D.,
MSCE, from
the Mayo Clinic physical medicine and rehabilitation, said. “Our best hope is
to prevent
people from getting it.”
To do that, she’s
testing a new technique that combines CT scans with Spect-imaging. That
powerful combo
pinpoints exact locations of critical lymph
nodes.
“The physicians who are planning a woman’s radiation can know
exactly where those critical nodes are and
avoid them, block them
from the radiation field, ”Dr. Cheville said.
Studies show it reduces
the number of critical lymph nodes that receive harmful radiation by more than
55
percent.
“We treated 30 women. None of those women have
developed lymphedema,” Dr. Cheville said.
Katie was one of those
women.
“At the moment, I’m very pleased with the result. Two years have
passed. I have no symptoms,” Katie said.
Doctor Cheville says one big
advantage of this new approach is many medical centers already have both of
these imaging technologies. Training physicians to fuse the two
techniques for this purpose may be all that’s
needed to help women
reduce their risk of lymphedema
BACKGROUND: Between 5 percent
and 40 percent of women are estimated to experience some form of
lymphedema after breast cancer surgery; however, the condition is often
overlooked or misdiagnosed.
Lymphedema occurs when the lymph system
is damaged or blocked. It can cause fluid buildup and swelling
and
usually affects an arm or a leg, but it can affect other parts of the body.
Lymph fluid, tumors, lymph
vessels and lymph nodes all can play a
part in lymphedema. (SOURCES: www.breastcancer.org, www.
cancer.gov)
CAUSES AND SYMPTOMS: Lymphedema can be either
primary or secondary. Primary lymphedema is
caused by abnormal
development and can occur at birth or develop later in life. Secondary
lymphedema is
caused by damage to the lymph system due to
infection, injury, cancer, scar tissue, or radiation therapy.
People
can be at risk of developing lymphedema if they are obese, smoke heavily, have
diabetes or have
had a mastectomy or previous surgery to the armpit
area. Along with swelling, people with lymphedema may
experience a
feeling of heaviness or tightness in the arm or leg. They may also feel aching
or discomfort and
possibly hardening of the skin around the
affected area.
(SOURCES: www.cancer.gov, www.breastcancer.org and Mayo
Clinic)
NEW PREVENTION TECHNIQUES: Using single photon emission computed
tomography (SPECT)
along with computerized tomography (CT) scans,
doctors may be able to offer substantial protection against
lymphedema. Although a person may have as many as 62 lymph nodes under
the arm, only a few are
responsible for the removal of fluids from
the arm. The SPECT-CT technique works best for patients who
do not
require radiation targeting any remaining lymph nodes. The risk of developing
lymphedema may be as
much as 50 percent without taking measures to
preserve the function of a person’s lymphatic system.
Because
lymphedema can occur years after a surgery, patients will continue to be
monitored by their
physicians for signs of lymphedema. Currently,
there are two treatment plans for each patient: a standard
plan and
one adapted for lymph node sparing based on the SPECT-CT scans. (SOURCE: Mayo
Clinic)
Reducing Lymphedema -- In Depth Doctor's Interview
Andrea
Cheville, MD, MSCE, from the Mayo Clinic -- Physical Medicine and
Rehabilitation, talks about a
new way to potentially prevent
lymphedema
Tell me what lymphedema is.
Dr. Cheville: Lymphedema is a
potentially devastating condition that’s characterized by enlargement of a
body part because of the build-up of protein rich fluid. And it’s
unfortunate for many reasons it places
patients at risk of bad
medical events, recurrent infections, un-healing wounds. But beyond that it
changes
the way they look, it distorts them, you know you have a
very big head or a very big arm. It’s unattractive
and so I think
socially it’s a very difficult condition for people. It’s also uncomfortable
and currently we
cannot cure it. We can control it through a
collection of burdensome and very time-consuming self
management
activities. Which are wrapping and wearing compression garments which patients
never like it’s
always difficult for them. So right now and our best
hope is really to prevent people from getting it.
Once you get it are
you always going to have it?
Dr. Cheville: Yes.
So even if you
can control it you still have it and you have to keep doing the
control?
Dr. Cheville: The way I explain it to patients sometimes is if
you have a little town that gets bigger and you
don’t expand its
sewage system and so every time you have a heavy rain it has a potential to
flood. So you
just have more production than the system can handle
and so you always have the potential for overload.
We have lots of
therapeutic tricks we do to even that out so that patients can handle, can
remove the
amount of swelling, fluid that their body brings to
their tissue. But again it’s not easy for them. There’s no pill,
there’s no surgical procedure that can make this go away.
And
why does it occur?
Dr. Cheville: Well, so we have two sets of pipes, you
can kind of think of it as plumbing, that the arteries
bring lots of
fluid, an astounding amount of fluid into your body tissues every minute of the
day. And the way
that fluid gets out most of it is through the
veins but there’s a second set of pipes that most of us don’t know
about until you get lymphedema and when they stop working. But what the
lymphatics are responsible for
doing is removing about five percent
of the fluid that comes in to tissue during the day but they’re really,
really good at carrying out large solid waste. That is what they are
uniquely designed to do so bacteria, large
fats, large proteins
that’s really the specialty of the lymphatic system. And when patients undergo
cancer
treatment, in fact in the developed world certainly in the
United States that’s the number one cause of
lymphedema. We injure
the system by removing lymph nodes or irradiating lymph nodes in order to stage
a
cancer or to treat a cancer.
So women with breast cancer
are prime candidates to get this right?
Dr. Cheville:
Absolutely.
Is that because of where you’re treating because if you have
pancreatic cancer you’re not near the lymph
nodes in the arms, is
it the area that you’re treating?
Dr. Cheville: Yeah, that’s a part of
it. So you ask the great question of why once you take out those lymph
nodes you’ve damaged the system, you’ve interrupted the pipe, the
plumbing so in essence it’s a plumbing
issue. But we do we focus on
the fluid but what we really worry about is all that big waste material that it
can
build up in the tissue and cause a lot of problems. And so with
breast cancer treatment is changing so we are
less aggressive with
our treatment. We used to always take every last lymph node out of a woman’s
armpit.
Now we don’t we do a special technique to try and identify
the nodes that might have cancer. We take
those out first see if
they have any tumor cells and if they don’t we leave the rest of the nodes. So
some of
the good news is that there’s less lymphedema now in women
with breast cancer. But for those women who
do have all the nodes
in their armpit taken out they are at high risk of developing lymphedema in the
arm on
the same side but also in their trunk the front and back of
their upper trunk as well as their breast if they’ve
elected for
conservative treatment.
Are there some lymph nodes that are more
critical for draining fluids than other?
Dr. Cheville: They all drain
fluid. There’s a lot that we don’t understand about the lymphatic system. There
are lots of layers, eventually lymph is going to be dumped back in
to the bloodstream and as I said some of
that solid material that
the body picked up is bacteria and the last thing the body wants to do is put
bacteria
in the bloodstream. So what happens to the lymph is it
gets purified time and time again in lymph nodes and
certain lymph
nodes are kind of responsible for certain drainage territories. So you have
certain nodes that
drain the breast and certain nodes that drain
the arm. And from what we’ve found they’re usually one to at
most
three nodes that are kind of the first order that receive most of the lymph
from the breast. Other lymph
nodes are going to get that lymph
later to purify it again and again to make absolutely sure that we don’t
introduce something harmful into the blood stream.
So people get
this because you’re removing the nodes or irradiating the area, you’re not
exactly meaning to
irradiate those lymph nodes?
Dr.
Cheville: Exactly. Well sometime we do. If we think that a woman is at very
high risk of the cancer
coming back then we have to. The priority
is saving her life and avoiding a breast cancer related death. So
we absolutely have to irradiate the nodes in her armpit and often we
irradiate the nodes at the base of her
neck as well to sterilize
the field of any tumors cells. But for women who we don’t think they need
radiation
to their lymph nodes we did what’s called a sentinel node
biopsy, we took a few nodes we looked at them
we don’t think she
has any cancer in her lymph nodes then we want to spare them by all means.
Because
that reduces her risk of ultimately of developing incurable
lymphedema. What we found in our research was
that women who were
just receiving radiation to the breast, they’ve decided to keep their breast
and not
have the mastectomy so there we’re irradiating the breast to
get rid of any tumor cells. What we found is
about forty percent of
the time even though we’re not targeting them the nodes that drain the arm are
receiving potentially harmful doses of radiation.
Tell me
what you’re studying because prevention is what you’re going for there is no
cure.
Dr. Cheville: Our hope is to do everything we can while a woman
goes through primary breast cancer
treatment to reduce her risk of
ever developing lymphedema. We’ve earned the luxury in cancer treatment
now about worrying about patients quality of life. We’ve gotten very
good at curing people particularly
patients with early stage breast
cancer and now we’re able to broaden our focus and start to refine our
treatments so that they do the least damage possible to normal tissues.
And that’s really the theme of my
research. We know that as I said
surgically removing the lymph nodes and radiating the lymph nodes is what
injures the system and increases a woman’s likelihood of developing
lymphedema. The surgeons have done
a fabulous job of steadily
reducing the unnecessary surgical damage but we haven’t done much to reduce a
woman’s radiation exposure. So we’ve developed a technique where we
identify the lymph nodes. We go
for arm drainage because that’s
where most women will develop bad lymphedema. We worry about the
breast, the trunk but it turns out that the body is very good at
developing other pathways to drain the lymph
but they can’t do that
in the arm because it’s all got to get out of the arm. So our work is focused
on
protecting that are the first order recipients of lymph from the
arm.
So how many of the lymph nodes in the arm area are you removing or
are you trying to protect all of them?
Are there critical ones that
you don’t want to remove?
Dr. Cheville: The way we identify these lymph
nodes is we inject a very small amount of radioactive tracer in
the
back of the hand and the inner part just inside the elbow. And it’s very safe
this is a very routine
procedure, it’s something we do thousands of
times a day in the United States. But we’re using this
technique in
a slightly different way. We introduce the tracer just below the skin that
causes a bee sting that
goes away quickly and then that tracer
because it’s linked to a big molecule, a big solid material so the
lymphatics take that up and they transport it back to the critical
nodes that are draining the arm. And usually
we find that’s about
one to three and those are the nodes we want to spare. And almost always
there’s one
node that takes up a lot more tracer than the
other.
So is there an average in a woman, ten nodes or three
nodes?
Dr. Cheville: If a woman has only undergone what we call a
sentinel lymph node biopsy, and to identify the
nodes that are
draining the breast we use exactly the same technique, we put the same
radiolabel tracer in
her breast and we identify the nodes that are
draining the breast, look at those for cancer cells and as I
mentioned if they’re clean we leave the rest of the nodes. So in a
woman who has only undergone that
procedure her sentinel node,
which is the name of the nodes that light up when we inject the breast, if the
sentinel node is negative and we inject the arm usually we see on
average two point four nodes. However if
a woman has undergone what
we call a completion axillary dissection, that’s when the sentinel node was
positive, so we have to take most of the remaining nodes in her armpit
and we inject her arm we see from
between five and seven lymph
nodes. And what that reflects is that the lymph is trying to get back. It’s
trying
very hard to make its way back through the system but the big
channel is gone because the nodes that
usually are the first
recipients of the lymph have been surgically removed. So that lymph is going to
all kinds
of different nodes trying to work its way back and forge
new drainage pathways.
So what is the imaging technique called that
you’re using?
Dr. Cheville: SPECT.
Can you tell me what it stands
for?
Dr. Cheville: Single photonic emission computed
tomography.
So is it called the SPECT CT?
Dr. Cheville: Yeah,
SPECT stands for single photon emission computed tomography and it combines two
techniques. We have what are called Gama cameras that pick up
radioactivity so they do a fabulous job of
identifying where that
tracer that we injected into a woman’s arm where that goes and which nodes now
have the tracer. But it doesn’t tell us, if we have a picture we
just see black dots which isn’t very
informative. A CAT scan gives
us a lot of anatomic detail and when we put those two scans together we can
see exactly where those critical nodes are located in the
body.
Is the imaging technique new or is using it in this way
new?
Dr. Cheville: Using it in this way is new.
So hospitals
across the country use this technique in other imaging needs?
Dr.
Cheville: That’s one of the strengths of this technique is that the technology
is widely available in most
medical centers.
So it’s really
the combining of the two that’s this new approach, is it something that people
would have to go
through training or could most labs do
it?
Dr. Cheville: Most labs, the tricky thing it turns out is not
acquiring the images. What we do, the goal of the
research is to
take the SPECT CT and to fuse it with the CAT scans that are used in radiation
planning. And
so we merge those images and that way the physicians
that are planning a woman’s radiation can know
exactly where those
critical nodes are and avoid them, block them from the radiation
field.
How are they blocked?
Dr. Cheville: It’s actually very
simple. They are able, now it’s computerized so they’re able to change the
field a little bit.
It’s so precise that they can just move it
over, nothing has to be laid over or anything like that?
Dr. Cheville:
No really it’s done on a computer.
What are the results of your study,
what have you seen?
Dr. Cheville: What we found and it exceeded our
wildest hopes we’ve been able to reduce the amount of
incidental
radiation. This is radiation that’s not therapeutic it’s not needed to reduce a
woman’s risk of
cancer, it’s the nodes are getting radiation they
don’t need. We’ve been able to reduce the number of nodes
getting
damaging doses by about fifty percent.
What were you thinking when you
saw the results?
Dr. Cheville: I was really delighted. It’s not a huge
deal for a woman to go through this, you know this scan.
It’s a
one-time deal and it may protect her for the rest. If we can incorporate this
technique it could protect
her from developing an incurable and
very, very difficult condition.
Reducing the incidental level of
radiation how does that translate in to the number of causes you’ve seen of
women with lymphedema? Have you see a drop in cases here?
Dr.
Cheville: We treated thirty women none of those women have developed
lymphedema. We did not have
a control group in this study so that’s
the next step is to get an estimate of lymphedema. Because protecting
the
nodes is nice but what we really want to do is eliminate lymphedema and so the
next step is a
randomized controlled trial.
Is that
something you’re working on now?
Dr. Cheville: I’m working on getting
funding.
This is something that could be adopted by hospitals across the
country even though they could start doing
this now or you need to
do the randomized control trial to make sure this is worth it and really
meaningful?
Dr. Cheville: What really supports what we do in Western
medicine is the strength of the evidence that
supports it. And so we
do a lot of things that don’t have a strong evidence base I feel very
passionately that
we have good evidence. And so my colleagues and
co-investigators want very much to just offer this to
women, It’s
kind of a why would you not. Why would you not there’s no harm, really SPECT is
a very safe
technique we’ve never had any adverse events from the
injection so their question is why would you not. If
we have the
opportunity to even spare one patient from lymphedema it’s not prohibitively
expensive, it’s not
challenging for patients. But as a scientist I
feel we really do have to do this right.
Let’s say you have this
randomized study and what you see then is what you see now what would this do
for
women, what kind of impact would this have?
Dr. Cheville:
That’s a tricky question to answer because in my clinical work and I treat
lymphedema but I
became passionate about this because I experience
firsthand how frustrated women become trying to
control this
condition indefinitely. And so over time my research interest came to focus on
prevention
because I think that’s our best shot at really helping
them. So in my clinical work I divide women in to,
breast cancer
survivors, into three categories. Those who have had a sentinel lymph node
biopsy only and
their risk of lymphedema is relatively low, it’s
about seven to ten percent. Numbers have been published up
to
seventeen percent and in part it reflects that we haven’t followed these women
prospectively a long time.
So actually if in ten years we may find a
higher incidence of lymphedema in the group but they are at the
least risk. Then you take women who are in the middle group they have
had all of their or most of their
lymph nodes in their armpits
removed but they didn’t need radiation to the armpit. I think those are the
women who will really benefit from this technique because their risk
may approach forty percent, their
lifetime risk of developing
lymphedema. And I think that’s the group that we can really help with this.
Then
the third group is those women who present with later stage
disease and we simply have to treat them very
aggressively. We have
to radiate all the nodes to protect them from recurrent cancer. And there are
other
strategies that we’re looking at for that group of women. But
it’s really that middle group.
And so for that group how would this
affect their lives, how would this change their future if this
works?
Dr. Cheville: I think in two important ways, one there’s a lot of
peace of mind of not being at risk for
lymphedema. Because
lymphedema is harmful not just having it, that’s a kind of indefinite burden
that
plagues women. It affects their work performance, their
psychological well being, their familial rolls, it really
undermines every quality of life domain. So avoiding it is critical but
even knowing that you’re at risk is very
distressing for women.
They are frightened, we don’t always do a great job of educating them in the
means
that they can reduce their risk. So I think giving women
peace of mind even if they never develop
lymphedema that their risk
has been substantially reduced is a very valuable contribution.
People
that do radiation must hear that a lot, that I’m scared of getting lymphedema
because people have
had friends or family that had it.
Dr.
Cheville: The internet, the internet is a blessing and a curse but you can
certainly very quickly call up
some gruesome pictures of lymphedema
with a brief search. And it frightens women
terribly.
Dana Wirth Sparks
Mayo Clinic Department of
Public Affairs
(507) 538-0844
[email protected]
http://www.mayoclinic.org/medical-edge/
http://newsblog.mayoclinic.org
http://socialmedia.mayoclinic.org/
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