Pneumatic Compression for Post-Mastectomy Lymphedema: Just a Lot of Air
Pneumatic Compression for Post-Mastectomy Lymphedema: Just a Lot of Air
ABSTRACT & COMMENTARY
Synopsis: A randomized study failed to demonstrate that pneumatic compression was more effective than no therapy in the control of lymphedema in women with breast cancer.
Source: Dini D, et al. Ann Oncol 1998;9:187-190.
A serious local complication of breast cancer therapy, particularly axillary lymph node dissection combined with modified radical mastectomy, is the development of lymphedema of the arm. The incidence varies widely (10-33%), but severe symptoms occur in about 10-15% of individuals.1
Not only is lymphedema a cosmetic problem, but also a lymphedematous arm may be less functional, predisposed to infection, and may lead to serious depression. It is said that Ingrid Bergman referred to her own lymphedematous arm as "the beast" during her terminal illness. In rare instances, a second malignancy may arise in a lymphedematous arm; usually the tumor is a sarcoma, often of lymphatic vessels.
Treatment of lymphedema is most commonly mechanical. Compression garments such as elastic sleeves and intermittent pneumatic compression are often employed. However, the lack of a reproducible method of quantitating lymphedema has led to the generation of little objective evidence of efficacy. Dini and colleagues recently conducted a randomized study evaluating whether intermittent pneumatic compressions were more effective than no intervention in the control of lymphedema.
Patients with unilateral lymphedema following mastectomy were randomly assigned to receive no specific treatment or five, two-hour sessions of pneumatic compression at a constant pressure of 60 mmHg each week for two weeks, and this was repeated after a five-week interval. Lymphedema was defined as an absolute increase in circumference of the affected limb compared to the normal one. Circumference was measured in seven matching points on the two arms. Differences in the circumference measurements between the limbs at each point were added together to get a total delta score. Only patients with a baseline difference of 10 cm or greater were considered to have clinically significant lymphedema. All patients received information about skin care and prophylaxis. After the completion of the second course of pneumatic compression at nine weeks, lymphedema measurements were made again. Response was defined as a 25% or greater reduction in the difference between the lymphedematous and the normal arm. Progression was defined as a 25% or greater increase in the difference. Any change between these criteria was considered stable lymphedema.
Eighty patients were studied. Baseline characteristics were similar in the two groups including age and prior treatment. Lymphedema was mild to moderate at study entry and had been present less than one year. Eight patients in the control group (20%) and 10 patients in the treatment group (24%) had a reduction in lymphedema of greater than 25% of the sums of the circumferences (P = 0.59). The group receiving pneumatic compression had an overall statistically significant decrease in lymphedema, with the average difference in circumferences going from 16.1 cm (+ 5 cm) to 14.2 cm (+ 6 cm) (P = 0.009). No change was noted in the control group as a whole. However, the magnitude of the decrease was small and was felt not to be of clinical significance. Three patients randomly assigned to pneumatic compression refused further treatment and three were lost to follow-up.
COMMENTARY
Uncontrolled, clinical studies of physical therapy for arm lymphedema have reported reductions of 51-81% after intensive intervention with lymphatic massage, compression bandaging, use of compression garments and elastic sleeves, skin care, and special exercises.1 However, neither this randomized trial nor another comparing the use of an elastic sleeve to electrically stimulated lymphatic drainage2 demonstrated any apparent clinical benefit to physical manipulations. A major insight from this study is that about 20% of patients who followed the guidelines for good hygiene experienced a reduction in lymphedema. This result argues that all future studies will need to be controlled with a placebo or non-intervention arm.
Pharmacologic approaches may also aid a few patients. Diuretics are not very useful, but flavonoids have been reported to reduce lymphedema, perhaps by stimulating protein turnover in lymph fluid. 5,6 benzo-(a) pyrone3 and benzo-(g) pyrone4 have been reported to slowly reduce lymphedema, but these drugs are not routinely available. Fortunately, this problem should become increasingly rare in light of data previously discussed in Clinical Oncology Alert from NSABP B20 documenting that women with tumors larger than 1 cm appear to benefit from adjuvant therapy regardless of their nodal status. In addition, the approach to axillary staging of finding the sentinel node should also lead to a decrease in this distressing and intransigent side effect.
References
1. Morgan RG, et al. J Hand Surg 1992;17B:437-441.
2. Bertelli G, et al. Ann Oncol 1991;2:575-578.
3. Casley-Smith JR, et al. N Engl J Med 1993;329: 1158-1161.
4. Piller NB, et al. Br J Plastic Surg 1988;41:21-27.
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