Preoperative Upper Limb Lymphatic Function In Breast Cancer Surgery

Objective: To describe the preoperative upper limb lymphoscintigraphic pattern in women with breast cancer. Methods: Thirty-seven patients undergoing lymphoscintigraphy within 30 days of surgery were investigated. Lymphoscintigraphic studies of 37 upper limbs ipsilateral to surgery and 32 contralateral upper limbs were performed. The examination protocol consisted in obtaining static images of the upper limb in semi-flexion after 10 minutes, and 1 and 2 hours after subcutaneous injection of 1 mCi (37 MBq) of Tc-99m-dextran in the dorsum of the hand. The velocity of axillary lymph node visualization (I, visible at 10 minutes; II, 1 hour; III, 2 hours; and IV, invisible) and degree (intensity) of nodal uptake (a, marked; b, moderate; c,mild; and d, absent) were analyzed. Results: Optimal lymphatic functional pattern (Ia) was observed in four (11%) patients, in the ipsilateral upper limb, and six (19%), in the contralateral upper limb. Worse condition was observed in three (8%) patients (IVd) in the ipsilateral upper limb and two (6%) patients in the contralateral upper limb. The remaining patients showed intermediate states of velocity and uptake intensity. Conclusion: This study found relevant changes in preoperative lymphoscintigraphy, demonstrating preexisting functional differences in the lymphatic system. © 2011 Elsevier Editora Ltda.575530534Szuba, A., Pyszel, A., Jedrzejuk, D., Janczack, D., Andrzejak, R., Presence of functional axillary lymph nodes and lymph drainage within arms in women with ou without breast cancer-related lymphedema (2007) Lymphology, 40 (2), pp. 81-86Gashev, A.A., Zawieja, D.C., Physiology of human lymphatic contractility: A historical perspective (2001) Lymphology, 34, pp. 124-134Guyton, A.C., (1998) Tratado de Fisiologia Medica, , 8ed. Rio de Janeiro: Ed. Guanabara KooganWarren, A.G., Brorson, H., Borud, L.J., Slavin, S.A., Lymphedema: A comprehensive review (2007) Ann Plast Surg, 59, pp. 464-472Kiel, K.D., Rademacker, A.W., Early stage breast cancer: Arm edema after wide excision and breast irradiation (1996) Radiology, 198, pp. 279-283Ozaslan, C., Kuru, B., Lymphoedema after treatment of breast cancer (2004) Am J Surg, 18, pp. 69-72Soran, A., D'Angelo, G., Begovic, M., Ardic, F., Harlak, A., Wieand, S., Breast cancer-related lymphedema-what are the significant predictors and how they affect the severity of lymphdema? (2006) Breast J, 12 (6), pp. 536-543Lee, T.S., Kilbreath, S.L., Refshauge, K.M., Herbert, R.D., Beith, J.M., Prognostic of the upper limb following surgery and radiation for breast cancer (2008) Breast Cancer Res Treat, 110 (1), pp. 19-37Stanton, A.W., Modi, S., Mellor, R.H., Peters, A.M., Svensson, W.E., Levick, J.R., A quantitative lymphoscintigraphic evaluation of lymphatic function in the swollen hands of women with lymphoedema following breast cancer treatment (2006) Clin Sci (Lond), 110 (5), pp. 553-561Szuba, A., Shin, W.S., Strauss, W., Rockson, S., The third circulation: Radionuclide lymphoscintigraphy in the evaluation of lymphedema (2003) J Nucl Med, 44, pp. 43-57Szuba, A., Strauss, W., Sirsikar, S.P., Rockson, S.G., Quantitative radionuclide lymphoscintigraphy predicts outcome of manual lymphatic therapy in breast cancer-related lymphedema of the upper extremity (2002) Nucl Med Commun, 23 (12), pp. 1171-1175Cambria, R.A., Gloviczki, P., Naessens, J.M., Wahner, H.W., Noninvasive evaluation of the lymphatic system with lymphoscintigraphy: A prospective, semiquantitative analysis in 386 extremities (1993) J Vasc Surg, 18 (5), pp. 773-782O'Mahony, S., Rose, S.L., Chivers, A.J., Ballinger, J.R., Solanki, C.K., Barber, R.W., Finding an optimal method for imaging lymphatic vessels of the upper limb (2004) Eur J Nucl Med Mol Imaging, 31, pp. 555-563Ter, S.E., Alavi, A., Kim, C.K., Merli, G., Lymphoscintigraphy. A reliable test for the diagnosis of lymphedema (1993) Clin Nucl Med, 18 (8), pp. 646-654Weissleder, H., Weissleder, R., Lymphedema: Evaluation of qualitative and quantitative lymphoscintigraphy in 238 patients (1988) Radiology, 167, pp. 729-735Gloviczki, P., Calcagno, D., Schirger, A., Pairolero, P.C., Cherry, K.J., Hallet, J.W., Noninvasive evaluation of the swollen extremity: Experiences with 190 lymphoscintigraphy examinations (1989) J Vasc Surg, 9 (5), pp. 683-689Lane, K.N., Dolan, L.B., Worsley, D., McKenzie, D.C., Upper extremity lymphatic function at rest and during exercise in breast cancer survivors with and without lymphedema compared with healthy controls (2007) J Appl Physiol, 103 (3), pp. 917-925Scarsbrook, A.F., Ganeshan, A., Bradley, K.M., Pearls and pitfalls of radionuclide imaging of the lymphatic system. Part 2: Evaluation of extremity lymphoedema (2007) Brit J Radiol, 80, pp. 219-226(2000) Declaração de Helsinque III: Ehtical principles for research involving human subject, , http:www.ibemol.com.br/declaracoes/helsinque, Edinburgh, [cited 2000 oct 7]. Available from:Yuan, Z., Chen, L., Luo, Q., Zhu, J., Lu, H., Zhu, R., The role of radionuclide lymphoscintigraphy in extremity lymphedema (2006) Ann Nucl Med, 20 (5), pp. 341-344Howarth, D., Increased Lymphoscintigraphy flow pattern in the lower extremity under evaluation for lymphedema (1997) Mayo Clin Proc, 72 (5), pp. 423-429Bourgeois, P., Leduc, O., Leduc, A., Imaging techniques in the management and prevention of posttherapeutic upper limb edemas (1998) Cancer, 83 (12 SUPPL), pp. 2805-2813Altman, D.G., (1991) Pratical statistics for medical research, p. 611. , London: Chapman & Hall/CRCPurushotham, A.D., Britton, T.M.B., Klevesath, M.B., Chou, P., Agbaje, O.F., Duffy, S.W., Lymph node status and breast cancer-related lymphedema (2007) Ann Surg, 246, pp. 42-45Baulieu, F., Itti, R., Taieb, W., Richard, G., Martinat, H., Barsotti, J., Lymphoscintigraphy. A predictive test of post-traumatic lymphedema of the lower limbs (1985) Rev Chir Orthop Reparatrice Appar Mot, 71 (5), pp. 327-332Armer, J.M., Randina, M.E., Porock, D., Cullbertson, S.D., Predicting breast cancer-related lymphedema using self-reported symptoms (2003) Nurs Res, 52 (6), pp. 370-37

Evaluation Of Lymphatic Compensation By Lymphoscintigraphy In The Postoperative Period Of Breast Cancer Surgery With Axillary Dissection

Objective. To evaluate postoperative lymphatic compensation in the upper limb after mastectomy with axillary dissection. Subjects and methods. Twenty-three patients who underwent lymphoscintigraphy before and 60 days after surgery were enrolled from September 2006 to June 2007, in Campinas, Brazil. Protocol examination consisted in static imaging of each upper limb in semi-flexion and thoracic imaging after 10 min and 1 and 2 hr after subcutaneous injection of 1 mCi (37 MBq) of 99mTc dextran into the dorsum of the hand. A comparative analysis was made of hepatic uptake of the radiopharmaceutical, velocity of axillary lymph node visualization (I, visible at 10 min; II, at 1 hr; III, at 2 hr; IV, not visible) and degree (intensity) of uptake (a, marked; b, moderate; c, mild; d, absent) before and 60 days after surgery. Results. In the preoperative period, 3 (13%) patients were considered to have an optimal pattern (Ia) and 2 (9%) showed total involvement (IVd). Compared to velocity in the postoperative period, 9 (39%) patients showed no difference, 5 (22%) improved, 9 (39%) became worse, and one was considerably worse. Regarding the degree, 10 (43%) patients showed no difference, 9 (39%) became worse, and 4 (17%) improved. Regarding classification, 2 (9%) patients had an optimal lymphatic pattern (Ia) and 3 (13%) had total involvement (IVd). No patient presented decreased hepatic uptake after surgical treatment. Conclusions. The study found relevant changes in preoperative and postoperative lymphoscintigraphy, demonstrating the existence of functional differences in the lymphatic system of the upper limb. Alterations in lymphatic drainage pattern may already be perceived 60 days postoperatively, as can signs of lymphovenous anastomoses.973309315(2010) [INCA] National Cancer Institute [On Line], , http://www.inca.gov.br_[15Jan2010], Brazil. Health DepartmentSoran, A., D'Angelo, G., Begovic, M., Ardic, F., Harlak, A., Samuel, W.H., Vogel, V.G., Johnson, R.R., Breast cancer-related lymphedema - What are the significant predictors and how they affect the severity of lymphedema? (2006) Breast Journal, 12 (6), pp. 536-543. , DOI 10.1111/j.1524-4741.2006.00342.xWerner, R.S., Mccormick, B., Petrek, J., Arm edema in conservatively managed breast cancer: Obesity is a major predictive factor (1991) Radiology, 180, pp. 177-1784Guedes Neto, H.L., Arm edema after treatment for breast cancer (1997) Lymphology, 30, pp. 35-36Warren, A.G., Brorson, H., Borud, L.J., Slavin, S.A., Lymphedema: A comprehensive review (2007) Annals of Plastic Surgery, 59 (4), pp. 464-472. , DOI 10.1097/01.sap.0000257149.42922.7e, PII 0000063720071000000022Lee, T.S., Kilbreath, S.L., Refshauge, K.M., Herbert, R.D., Beith, J.M., Prognosis of the upper limb following surgery and radiation for breast cancer (2008) Breast Cancer Research and Treatment, 110 (1), pp. 19-37. , DOI 10.1007/s10549-007-9710-9Szuba, A., Shin, W.S., Strauss, H.W., Rockson, S., The third circulation: Radionuclide lymphoscintigraphy in the evaluation of lymphedema (2003) Journal of Nuclear Medicine, 44 (1), pp. 43-57Howarth, D., Increased Lymphoscintigraphy flow pattern in the lower extremity under evaluation for lymphedema (1997) Mayo Clin Proc, 72, pp. 423-429Gloviczki, P., Calcagno, D., Schirger, A., Pairolero, P.C., Cherry, K.J., Hallet, J.W., Wahner, H.W., Noninvasive evaluation of the swollen extremity: Experiences with 190 lymphoscintigraphy examinations (1989) J Vasc Surg, 9, pp. 683-689Bourgeois, P., Leduc, O., Leduc, A., Imaging techniques in the management and prevention of posttherapeutic upper limb edemas (1998) Cancer, 83 (12 SUPPL. AMERICAN), pp. 2805-2813Baulieu, F., Itti, R., Taieb, W., Richard, G., Martinat, H., Barsotti, J., Lymphoscintigraphy. A predictive test of post-traumatic lymphedema of the lower limbs (1985) Rev Chir Orthop Reparatrice Appar Mot, 71, pp. 327-332Scarsbrook, A.F., Ganeshan, A., Bradley, K.M., Pearls and pitfalls of radionuclide imaging of the lymphatic system. Part 2: Evaluation of extremity lymphoedema (2007) British Journal of Radiology, 80 (951), pp. 219-226. , DOI 10.1259/bjr/68256780Celebioglu, F., Perbeck, L., Frisell, J., Grondal, E., Svensson, L., Danielsson, R., Lymph drainage studied by lymphoscintigraphy in the arms after sentinel node biopsy compared with axillary lymph node dissection following conservative breast cancer surgery (2007) Acta Radiologica, 48 (5), pp. 488-495. , DOI 10.1080/02841850701305440, PII 778956448Szuba, A., Pyszel, A., Jedrzejuk, D., Janczak, D., Andrzejak, R., Presence of functional axillary lymph nodes and lymph drainage within arms in women with and without breast cancer-related lymphedema (2007) Lymphology, 40 (2), pp. 81-86Yuan, Z., Chen, L., Luo, Q., Zhu, J., Lu, H., Zhu, R., The role of radionuclide lymphoscintigraphy in extremity lymphedema (2006) Annals of Nuclear Medicine, 20 (5), pp. 341-344. , http://www.jsnm.org/cgi-bin/select.cgi?file=06070801&filetype=2Petrek, J.A., Pressman, P.I., Smith, R.A., Lymphedema: Current issues in research and management (2000) CA Cancer J Clin, 50, pp. 292-307Szuba, A., Strauss, W., Sirsikar, S.P., Rockson, S.G., Quantitative radionuclide lymphoscintigraphy predicts outcome of manual lymphatic therapy in breast cancer-related lymphedema of the upper extremity (2002) Nuclear Medicine Communications, 23 (12), pp. 1171-1175. , DOI 10.1097/00006231-200212000-00004O'Mahony, S., Rose, S.L., Chilvers, A.J., Ballinger, J.R., Solanki, C.K., Barber, R.W., Mortimer, P.S., Peters, A.M., Finding an optimal method for imaging lymphatic vessels of the upper limb (2004) European Journal of Nuclear Medicine and Molecular Imaging, 31 (4), pp. 555-563Kim, C., Li, B., Papaiconomou, C., Zakharov, A., Johnston, M.G., Functional impact of lymphangiogenesis on fluid transport after lymph node excision (2003) Lymphology, 36 (3), pp. 111-119(2000) Ethical Principles for Medical Research Involving Human Subjects (On Line), , http//:www.ibemol.com.br/declaracoes/helsinque, World Medical Association Declaration of Helsinki: Edinburgh, Scotland. Out 7thAltman, D.G., (1991) Practical Statistics for Medical Research, , 1st edn Chapman &ampHall, LondonSuami, H., Pan, W.-R., Taylor, G.I., Changes in the lymph structure of the upper limb after axillary dissection: Radiographic and anatomical study in a human cadaver (2007) Plastic and Reconstructive Surgery, 120 (4), pp. 982-991. , DOI 10.1097/01.prs.0000277995.25009.3e, PII 0000653420070915000022Foldi, E., Foldi, M., Clodius, L., The lymphedema chaos: A lancet (1989) Annals of Plastic Surgery, 22 (6), pp. 505-515Clodius, L., Minimizing secondary arm lymphedema from axillary dissection (2001) Lymphology, 34, pp. 106-110Gashev, A.A., Zawieja, D.C., Physilogy of human lymphatic contractility: A historical perspective (2001) Lymphology, 34 (3), pp. 124-134Purushotham, A.D., Britton, T.M.B., Klevesath, M.B., Chou, P., Agbaje, O.F., Duffy, S.W., Lymph node status and breast cancer-related lymphedema (2007) Annals of Surgery, 246 (1), pp. 42-45. , DOI 10.1097/01.sla.0000259390.51203.7b, PII 000006582007070000000

Evaluation Of Lymphatic Compensation By Lymphoscintigraphy In The Postoperative Period Of Breast Cancer Surgery With Axillary Dissection [avaliação Das Compensações Linfáticas No Pós-operatório De Câncer De Mama Com Dissecção Axilar Através Da Linfocintilografia]

The lymphatic system is a component of the human body that is closely related to the venous system. However, scientific knowledge of this system is limited. The etiology and risk factors for the development of postoperative lymphedema in patients with breast cancer seem to bemultifactorial and have not been fully understood yet. The objective of this review of the literature was to describe lymphoscintigraphic pattern and to evaluate upper limb lymphatic compensation following breast cancer surgery with axillary dissection. Copyright© 2008 by Sociedade Brasileira de Angiologia e de Cirurgia Vascular.74370375Instituto Nacional do Câncer (INCA) [site na Internet]. Brasil, Ministério da Saúde2007. [citado, , http://www.inca.gov.br, 30 dez 2007, Disponível emSoran, A., D'Angelo, G., Begovic, M., Breast cancer-related lymphedema: What are the significant predictors and how they affect the severity of lymphedema? (2006) Breast J, 12, pp. 536-543Werner RS, McCormick B, Petrek J, Cox L, Cirrincione C, Gray JR. Armedema in conservatively managed breast cancer: obesity is a major predictive factor. Radiology. 1991;180:177-84Guedes Neto, H.I., Armedema after treatment for breast cancer (1997) Lymphology, 30, pp. 35-36Warren, A.G., Brorson, H., Borud, L.J., Slavin, S.A., Lymphedema: A comprehensive review (2007) Ann Plast Surg, 59, pp. 464-472Lee, T.S., Kilbreath, S.L., Refshauge, K.M., Herbert, R.D., Beith, J.M., Prognosis of the upper limb following surgery and radiation for breast cancer (2007) Breast Cancer Res Treat. 2008, 110, pp. 19-37. , Epub Sep 26Szuba, A., Shin, W.S., Strauss, H.W., Rockson, S., The third circulation: Radionuclide lymphoscintigraphy in the evaluation of lymphedema (2003) J Nucl Med, 44, pp. 43-57The diagnosis and treatment of peripheral lymphedema (2003) Lymphology, 36, pp. 84-91. , Consensus Document of International Society of LymphologyVignes, S., Arrault, M., Dupuy, A., Factors associated with increased breast cancer-related lymphedema volume (2007) Acta Oncol, 46, pp. 1138-1142Kiel, K.D., Rademacker, A.W., Early stage breast cancer: Arm edema after wide excision and breast irradiation (1996) Radiology, 198, pp. 279-283Foldi, E., Foldi, M., Clodius, L., The lymphedema chaos: A lancet (1989) Ann Plast Surg, 22, pp. 505-515Gashev, A.A., Zawieja, D.C., Physiology of human lymphatic contractility: A historical perspective (2001) Lymphology, 34, pp. 124-134Guyton AC. Tratado de Fisiologia Medica. Rio de Janeiro: Guanabara Koogan1998Suami, H., Pan, W.R., Taylor, G.I., Changes in the lymph structure of the upper limb after axillary dissection: Radiographic and anatomical study in human cadaver (2007) Plast Reconstr Surg, 120, pp. 982-991Kim, C., Li, B., Papaiconomou, C., Zakharov, A., Johnston, M., Functional impact of lymphangiogenesis on fluid transport after lymph node excision (2003) Lymphology, 36, pp. 111-119Clodius, L., Minimizing secondary arm lymphedema from axillary dissection (2001) Lymphology, 34, pp. 106-110Howarth, D.M., Increased lymphoscintigraphy flow pattern in the lower extremity under evaluation for lymphedema (1997) Mayo Clin Proc, 72, pp. 423-429Hwang, J.H., Kwon, J.Y., Lee, K.W., Changes in lymphatic function after complex physical therapy for lymphedema (1999) Lymphology, 32, pp. 15-21Bourgeois P, Leduc O, Leduc A. Imaging techniques in the management and prevention of posttherapeutic upper limb edemas. Cancer. 1998;83(12 Suppl American):2805-13Svensson, W., Glass, D.M., Bradley, D., Peters, A.M., Measurement of lymphatic function with technetium-99m-labelled polyclonal immunoglobulin (1999) Eur J Nucl Med, 26, pp. 504-510Gloviczki, P., Calcagno, D., Schirger, A., Noninvasive evaluation of the swollen extremity: Experiences with 190 lymphoscintigraphy examinations (1989) J Vasc Surg, 9, pp. 683-689. , discussion 690Yuan, Z., Chen, L., Luo, Q., Zhu, J., Lu, H., Zhu, R., The role of radionuclide lymphoscintigraphy in extremity lymphedema (2006) Ann Nucl Med, 20, pp. 341-344Scarsbrook, A.F., Ganeshan, A., Bradley, K.M., Pearls and pitfalls of radionuclide imaging of the lymphatic system. Part 2: Evaluation of extremity lymphoedema (2006) Bri J Radiol. 2007, 80, pp. 219-226. , Epub May 25Williams, W.H., Witte, C.L., Witte, M.H., Mcneill, G.C., Radionuclide lymphangioscintigraphy in the evaluation of peripheral lymphedema (2000) Clin Nucl Med, 25, pp. 451-464Cambria, R.A., Gloviczki, P., Naessens, J.M., Wahner, H.W., Noninvasive evaluation of the lymphatic system with lymphoscintigraphy: A prospective, semiquantitative analysis in 386 extremities (1993) J Vasc Surg, 18, pp. 773-782O'Mahony, S., Rose, S.L., Chilvers, A.J., Finding an optimal method for imaging lymphatic vessels of the upper limb (2004) Eur J Nucl Med Mol Imaging, 31, pp. 555-563Szuba, A., Strauss, W., Sirsikar, S.P., Rockson, S.G., Quantitative radionuclide lymphoscintigraphy predicts outcome of manual lymphatic therapy in breast cancer-related lymphedema of the upper extremity (2002) Nucl Med Commun, 23, pp. 1171-1175Ter, S.E., Alavi, A., Kim, C.K., Merli, G., Lymphoscintigraphy. A reliable test for the diagnosis of lymphedema (1993) Clin Nucl Med, 18, pp. 646-654Lane, K.N., Dolan, L.B., Worsley, D., Mckenzie, D.C., Upper extremity lymphatic function at rest and during exercise in breast cancer survivors with and without lymphedema compared with healthy controls (2007) J Appl Physiol, 103, pp. 917-925Weissleder, H., Weissleder, R., Lymphedema: Evaluation of qualitative and quantitative lymphoscintigraphy in 238 patients (1988) Radiology, 167, pp. 729-735Petrek, J.A., Pressman, P.I., Smith, R.A., Lymphedema: Current issues in research and management (2000) CA Cancer J Clin, 50, pp. 292-307Baulieu, F., Itti, R., Taieb, W., Richard, G., Martinat, H., Barsotti, J., Lymphoscintigraphy. A predictive test of post-traumatic lymphedema of the lower limbs (1985) Rev Chir Orthop Reparatrice Appar Mot, 71, pp. 327-332Nos, C., Lesieur, B., Clough, K.B., Lecuru, F., Blue dye injection in the arm in order to conserve the lymphatic drainage of the arm in breast cancer patients requiring an axillary dissection (2007) Ann Surg Oncol, 14, pp. 2490-249

Impact of COVID-19 on Cardiovascular Testing in the United States Versus the Rest of the World

Objectives: This study sought to quantify and compare the decline in volumes of cardiovascular procedures between the United States and non-U.S. institutions during the early phase of the coronavirus disease-2019 (COVID-19) pandemic. Background: The COVID-19 pandemic has disrupted the care of many non-COVID-19 illnesses. Reductions in diagnostic cardiovascular testing around the world have led to concerns over the implications of reduced testing for cardiovascular disease (CVD) morbidity and mortality. Methods: Data were submitted to the INCAPS-COVID (International Atomic Energy Agency Non-Invasive Cardiology Protocols Study of COVID-19), a multinational registry comprising 909 institutions in 108 countries (including 155 facilities in 40 U.S. states), assessing the impact of the COVID-19 pandemic on volumes of diagnostic cardiovascular procedures. Data were obtained for April 2020 and compared with volumes of baseline procedures from March 2019. We compared laboratory characteristics, practices, and procedure volumes between U.S. and non-U.S. facilities and between U.S. geographic regions and identified factors associated with volume reduction in the United States. Results: Reductions in the volumes of procedures in the United States were similar to those in non-U.S. facilities (68% vs. 63%, respectively; p = 0.237), although U.S. facilities reported greater reductions in invasive coronary angiography (69% vs. 53%, respectively; p < 0.001). Significantly more U.S. facilities reported increased use of telehealth and patient screening measures than non-U.S. facilities, such as temperature checks, symptom screenings, and COVID-19 testing. Reductions in volumes of procedures differed between U.S. regions, with larger declines observed in the Northeast (76%) and Midwest (74%) than in the South (62%) and West (44%). Prevalence of COVID-19, staff redeployments, outpatient centers, and urban centers were associated with greater reductions in volume in U.S. facilities in a multivariable analysis. Conclusions: We observed marked reductions in U.S. cardiovascular testing in the early phase of the pandemic and significant variability between U.S. regions. The association between reductions of volumes and COVID-19 prevalence in the United States highlighted the need for proactive efforts to maintain access to cardiovascular testing in areas most affected by outbreaks of COVID-19 infection