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Topic: Lymphedema confusion

Forum: Lymphedema — Risks, tips for prevention, and info about products that can address the symptoms of lymphedema.

Posted on: Jul 31, 2017 11:11PM

Connie1230 wrote:

I have been participating in a lymphedema clinical trial. Today they did the measurements for the first time in several months. As I've lost weight during chemo, the only thing I could assume they could go by were comparisons between the 2 arms. The girl who did this said there was an 8% difference which qualified for pre-lymphedema. If there's an 8% difference, it certainly isn't visible and I have absolutely no symptoms or issues with this arm. It is my left arm and I am left handed so this Would be my predominant arm.

They want me to wear the sleeve and glove, which they provided, 12 hrs a day for 28 days. Now, my issue with this is that I have brachioradial pruritus in my arms(an itching condition) and live in FL so there's no break from the heat.

When I pretty much made it clear that 12 hrs. Couldn't happen unless I intend to become a hermit and never go outside, they backed down big time and said to do whatever I could.

The girl doing all the measurements has been doing this only since March and I guess I'm really questioning these results. I was in such shock that I didn't get the difference in measurements in cms but when I went to see the radiologist, her nurse couldn't get any difference in measurements. The radiologist herself, raised her eyebrows and said that she could tell by my hands that if I had any, it was minimal. I have zero swelling in them. In fact after my 20 lb weight loss during chemo, I rarely wear my rings because they've slipped off my fingers in the pool twice and I fear losing them.

So for those of you that do have lymphedema even slightly, I guess what I want to know is do any of you have no symptoms? If it weren't for this clinical trial, I can't see that's there's any way I'd have any clue based on the radiology arm measurements. I'm just very confuse and was so shocked that the questions didn't occur until I was on my way home.

Dx 7/1/2016, IDC, Left, 4cm, Stage IIB, Grade 3, 0/4 nodes, ER-/PR-, HER2- Surgery 8/24/2016 Lumpectomy; Lymph node removal: Sentinel Chemotherapy 10/10/2016 Adriamycin (doxorubicin), Carboplatin (Paraplatin), Cytoxan (cyclophosphamide), Taxol (paclitaxel)
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Aug 1, 2017 01:58AM ChiSandy wrote:

My only symptoms (now that the cording is gone) are that the “edgier” charms on my fake Pandora Medic-Alert bracelet (don’t worry, it’s loose) make little impressions in my skin, as do creases and seams (but only slightly more than my “control” arm); and if the barometric pressure outside drops sharply (like when a storm is about to start), my ring gets tight. Know that your dominant arm will usually measure a bit bigger due to muscular development. My LE doc likes to use either electro-impedance testing (most insurance & Medicare won’t pay for it), or good ol’-fashioned water displacement a la Archimedes. A larger arm will displace more water. (He also subtracts an allowance for the fact that my affected arm is the dominant one). When I was first diagnosed with LE and had a Stage 1 flare shortly thereafter, the only visible difference was that my LE hand looked “younger” (less wrinkly & less veined). Back now to Stage 0 (subclinical), you really can’t tell the difference unless I’ve just taken my bracelet off.

Diagnosed at 64 on routine annual mammo, no lump. OncotypeDX 16. I cried because I had no shoes...but then again, I won’t get blisters.... Dx 9/9/2015, IDC, Right, 1cm, Stage IA, Grade 2, 0/4 nodes, ER+/PR+, HER2- Surgery 9/22/2015 Lumpectomy: Right Radiation Therapy 11/1/2015 3DCRT: Breast Hormonal Therapy 12/30/2015 Femara (letrozole)
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Aug 2, 2017 10:16PM Connie1230 wrote:

I had to google to find out what cording was. I have read and read and still cannot find a single symptom that I have. Do you wear a sleeve routinely ChiSandy? I'm getting a bit weary of belonging to clubs that I never wanted to join.

Dx 7/1/2016, IDC, Left, 4cm, Stage IIB, Grade 3, 0/4 nodes, ER-/PR-, HER2- Surgery 8/24/2016 Lumpectomy; Lymph node removal: Sentinel Chemotherapy 10/10/2016 Adriamycin (doxorubicin), Carboplatin (Paraplatin), Cytoxan (cyclophosphamide), Taxol (paclitaxel)
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Aug 3, 2017 01:01AM ChiSandy wrote:

I always wear sleeve & gauntlet in the gym for training sessions, but I only go 2-3x/wk. For treadmill & exercise bike, if I haven’t had a training session beforehand, I don’t need to wear it; but for the rowing machine I do because of the arms pumping. I don’t do elliptical because I just can’t get the hang of it without straining my knees (if they had a recumbent elliptical like they do at Athletico, where I did outpatient PT after my knee replacements, I’d be all over it like a cheap suit). I used to wear compression for playing guitar, but now I do only when playing a dreadnought (deeper body that my arm can’t completely fit over) or outdoors in 90F+ heat.

Diagnosed at 64 on routine annual mammo, no lump. OncotypeDX 16. I cried because I had no shoes...but then again, I won’t get blisters.... Dx 9/9/2015, IDC, Right, 1cm, Stage IA, Grade 2, 0/4 nodes, ER+/PR+, HER2- Surgery 9/22/2015 Lumpectomy: Right Radiation Therapy 11/1/2015 3DCRT: Breast Hormonal Therapy 12/30/2015 Femara (letrozole)
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Aug 3, 2017 01:30AM VLevic wrote:

Hi, Connie1230. I'm a PT and happens to also have a breast cancer. I recently just had a mastectomy with axillary node dissection. Currently, I don't have any arm lymphedema but have chest lymphedema. Our clinic treats lymphedema cases and there is a new testing called L-Dex that we used on all pre and post mastectomy patients and compare the numbers pre and post operative to determine if you have what we call a sub-clinical lymphedema. Sub-clinical is there is tissue fluid however not yet visible and our protocol for this patients are to wear UE compression, exercise program and education on self assisted manual lymph drainage. After 30 days, we measure through L-Dex again and if it's working then we discontinue use of the UE compression garment. There are cases that I have seen wherein the LDex number is negative for sub-clinical lymphedema however you will see very mild lymphedema. Our treatment plan is the same, compression, exercise , patient education and lymph drainage or MLD. Right now, my LDex number is low and does not denote sub-clinical lymphedema however I wear a compression garment without the gauntlet and for some reason, arm feels better. I only wore it for 2 days. The one that is bothering me a lot is my chest in which currently have a drain for 3 weeks now which led to a postponed last chemo session. Finally my plastic agreed for me to have the last one this Friday even with a drain. Compressions are good but I know the stamina to wear it can be a challenge particulalry in the hot weather. I have seen non-compliance of wearing it and I do totally understand why. Hang in there! I would try wearing it 2x /week and build it up from there and then taper it down back to to 2x/week. I suggest seeing a PT and learn how to do self manual lymph drainage.

Dx 7/2016, LCIS/ILC/IDC, Left, 2cm, Stage IIB, 1/16 nodes, ER+/PR+, HER2- Surgery 3/21/2017 Lymph node removal: Underarm/Axillary; Mastectomy: Left; Reconstruction (left): Tissue expander placement Surgery 3/22/2017 Lymph node removal: Left, Underarm/Axillary; Mastectomy: Left; Reconstruction (left): Tissue expander placement
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Aug 3, 2017 02:31AM Momine wrote:

If you have very slight LE, it is makes all kinds of sense, in my opinion, to get PT, wear the sleeve etc. It can reverse it and prevent it from taking off, at which point it gets difficult to treat.

Dx 6/1/2011, ILC, 5cm, Stage IIIB, Grade 2, 7/23 nodes, ER+/PR+, HER2- Chemotherapy 6/19/2011 Cytoxan (cyclophosphamide), Ellence (epirubicin), Fluorouracil (5-fluorouracil, 5-FU, Adrucil), Taxotere (docetaxel) Surgery 9/12/2011 Mastectomy: Left, Right Radiation Therapy 1/8/2012 Surgery 3/7/2012 Prophylactic ovary removal Hormonal Therapy 3/31/2012 Femara (letrozole)
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Aug 3, 2017 09:30AM Connie1230 wrote:

They never said a word about PT, lymph drainage or anything except wearing this blasted sleeve for 12 hrs a day. The only kind of testing that was done on me was measuring my arms in different locations. They're supposed to be calling me early next week and I will have all kinds of questions for them. This really makes no sense to me. If I truly have pre lymphedema shouldn't I be doing something other than wearing a sleeve? They've also given me no info on any of this. Of course, this is a clinical trial, not one of my drs. but it still makes no sense to me.

Dx 7/1/2016, IDC, Left, 4cm, Stage IIB, Grade 3, 0/4 nodes, ER-/PR-, HER2- Surgery 8/24/2016 Lumpectomy; Lymph node removal: Sentinel Chemotherapy 10/10/2016 Adriamycin (doxorubicin), Carboplatin (Paraplatin), Cytoxan (cyclophosphamide), Taxol (paclitaxel)
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Aug 3, 2017 05:49PM Outfield wrote:

Connie, circumference measurement is a notoriously bad way to diagnose lymphedema. First, it's not reproducible. Different examiners can't be predicted to get the same number. Second, you're right - if you use one arm a lot more than the other that arm will be bigger. I have spent my life playing throwing sports, and my throwing arm has been bigger all my life. Visible in a mirror degree of bigger. If you look at pictures of athletes that do an asymmetrical event, like pole vault or javelin, you can see that. That's why I've been steadily annoyed every time someone has measured my arms, said they're the same size, and been puzzled about how I could have lymphedema.

When I was diagnosed, my lymphedema was something that could be seen (loss of visibility of veins and contours in the forearm), felt by an examiner (skin pinch much thicker), and felt by me (felt like muscle injury that I could not stretch out), yet at that time my forearms were the same circumference. There's no doubt I have lymphedema: I've had flares where my arm got much larger, and I've been seriously ill with cellulitis (bacteria in my blood) twice.

Even though measuring circumference is a bad tool, it's cheap and easily available, so it's what is done most often.

It sounds like you're wondering how seriously to take this. Honestly, I'd jump on it, even if I weren't sure the diagnosis was correct. Try the sleeve. I live in a hot climate and I never notice my sleeve to be hot. It's totally perplexing, but the arm just does not feel warm. Ask if you can try a nightgarment, if wearing something at night sounds more tolerable. Ask to see a lymphedema therapist and get instruction in how to take care of yourself: wrapping, massage. I was so glad to know how to wrap when my arm swelled up too big to fit into any of my stuff. Go to www.stepup-speakout.org and educate yourself. A lot of official patient ed material is still behind the latest research. The worst that you can do is to worry unnecessarily and waste some time. The best you can do for yourself is to catch this early and start measures to keep it from getting out of hand.

Also, remember that everybody's lymphedema is unique. Just because one person experienced it one way does not mean that you would be expected to experience the same thing.

And just so you know: there is pretty much nothing I don't do because of lymphedema, except dunk my affected arm in something likely to be full of bacteria, like a hot tub.




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Aug 3, 2017 07:28PM Connie1230 wrote:

I am wearing the sleeve as long as I can stand it when I'm in the house. I have a condition called brachioradial pruritus which causes extreme itching in my arms. That is my issue with the sleeve. So it goes on and off with my ability to stand it without scratching my arm off. So it's like a double whammy in my arms.

This cancer is like the gift that keeps on giving, right? I have neuropathy in my feet even after wearing the frozen booties and mittens. Now this....I know that even if I do have this, a lot of people have it far worse. I guess I thought surgery, chemo, radiation and I'd be on the road to recovery and I am in most ways. I just really didn't expect this other....not that anyone does

Dx 7/1/2016, IDC, Left, 4cm, Stage IIB, Grade 3, 0/4 nodes, ER-/PR-, HER2- Surgery 8/24/2016 Lumpectomy; Lymph node removal: Sentinel Chemotherapy 10/10/2016 Adriamycin (doxorubicin), Carboplatin (Paraplatin), Cytoxan (cyclophosphamide), Taxol (paclitaxel)
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Aug 3, 2017 07:51PM Binney4 wrote:

Connie, here's a great page about how to recognize lymphedema that might be helpful to you:

http://www.stepup-speakout.org/What_does_lymphedem...

As Outfield suggests, getting a referral to a well-trained lymphedema therapist for an evaluation and help with managing your risk would be both reassuring and smart. Here's how to find a qualified therapist near you:

http://www.stepup-speakout.org/Finding_a_Qualified...

Hope you get good answers and support soon!

Gentle hugs,
Binney

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Aug 3, 2017 10:28PM Connie1230 wrote:

Thanks Binney4. I still cannot see a symptom after that first link. I didn't see a lymphedema specialist listed at Mayo Clinic in Jacksonville but I intend to find out this next week.

Dx 7/1/2016, IDC, Left, 4cm, Stage IIB, Grade 3, 0/4 nodes, ER-/PR-, HER2- Surgery 8/24/2016 Lumpectomy; Lymph node removal: Sentinel Chemotherapy 10/10/2016 Adriamycin (doxorubicin), Carboplatin (Paraplatin), Cytoxan (cyclophosphamide), Taxol (paclitaxel)
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Aug 4, 2017 01:23AM VLevic wrote:

Connie1230, before you went to a clinical trial, did you have the chance to meet who principal investigators of the trial, explain in verbal and written what are the criteria, complications and things that you have to do? The reason I asked is because I participated in an olive oil clinical trial for high risk breast cancer when I was diagnosed initially with a Stage 0. Before start, you will have to meet the people involve in the research and explain to you what is going on , the purpose of the clinical trial and other side effects as well as questionnaires. What is the clinical trial purpose and what is it's desired outcome? Yes, circumferential measurement of the arm at the moment is the only way to measure if you have any decrease in swelling or edema, that is if you do have it visibly. For sub-clinical lymphedema, it will be the LDEX. I strongly suggest that if wearing the compression garment is making your pruritus or itching worst, I will opt out of the clinical trial. For sure you can opt out before you decided to join it. There are other types of compresison that you use such as circaid by Juxta which is removable because it has velcros. There's a brand called "lympheDIVAs " that makes upper extermity compression garments. Theirs is infused with aloe vera so it does not feel hot and itchy. I actually have one and wear it everyday.

Dx 7/2016, LCIS/ILC/IDC, Left, 2cm, Stage IIB, 1/16 nodes, ER+/PR+, HER2- Surgery 3/21/2017 Lymph node removal: Underarm/Axillary; Mastectomy: Left; Reconstruction (left): Tissue expander placement Surgery 3/22/2017 Lymph node removal: Left, Underarm/Axillary; Mastectomy: Left; Reconstruction (left): Tissue expander placement
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Aug 4, 2017 01:33AM marijen wrote:

Outfield, how is a hot tub different from a public pool, or aren't they? I need to know pls

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Aug 4, 2017 03:24AM ChiSandy wrote:

A hot tub is hot enough to cause an LE flareup (ditto saunas & steam rooms). A public pool is not very hot—in fact, some indoor ones are not even heated in summer, and all are chlorinated. Not necessarily so for a hot tub—and though the water is very hot, it’s not hot enough to kill pathogens, and can even incubate them more effectively than can a heated swimming pool. The combination of an LE flare and the hot “bacterial soup” can land you in the hospital with cellulitis or heaven forbid, sepsis. That goes double if you have any cuts, scratches, or even invisible breaks in your skin.

Diagnosed at 64 on routine annual mammo, no lump. OncotypeDX 16. I cried because I had no shoes...but then again, I won’t get blisters.... Dx 9/9/2015, IDC, Right, 1cm, Stage IA, Grade 2, 0/4 nodes, ER+/PR+, HER2- Surgery 9/22/2015 Lumpectomy: Right Radiation Therapy 11/1/2015 3DCRT: Breast Hormonal Therapy 12/30/2015 Femara (letrozole)
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Aug 4, 2017 03:30AM marijen wrote:

What about an indoor heatedpool with an LE flare-up?

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Aug 4, 2017 03:03PM marijen wrote:

I just made my own compression sleeve - cut off the foot of a compression sock. Works good. I usually wear long sleeves, so noone's going to see it.

Not sure I want to go swimming with this new flare up. Still waiting on input from question above, I pick up sinus and eye infections (conjunctivitis) easily......

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Aug 8, 2017 02:52PM Outfield wrote:

I didn't mean exposure to the temperature. Even when chlorinated, hot tubs often have high bacteria counts, for reasons I used to understand (dated a health inspector for a long time) but don't remember. In medicine, there is a skin infection that has the name "hot tub folliculitis" because it is classically caught in a hot tub. The health inspector called them "diaper soup." I'm still in touch with him - will ask how this happens.

I have personally found that nothing terrible happens when I dunk the rest of me in hot water. I think that's the sort of thing that is going to be particular for a person, since we each have our own lymphedema.

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Aug 8, 2017 03:07PM ksusan wrote:

marijen, I have been prescribed by my LE therapist to use a heated, salt-water pool to reduce cording and provide compression. Salt kills a lot of pathogens, which may make the difference.

Mutant uprising quashed. Dx 1/2015, IDC, Right, Stage IIA, 1/1 nodes, ER+/PR+, HER2- Dx 1/2015, DCIS, Left, Stage 0, Grade 3, 0/2 nodes Hormonal Therapy Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Surgery Lymph node removal: Sentinel; Mastectomy: Left, Right Radiation Therapy Whole-breast Chemotherapy Cytoxan (cyclophosphamide), Taxotere (docetaxel)
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Aug 8, 2017 03:46PM - edited Aug 8, 2017 05:19PM by marijen

Oh thank you ksusan. We have one here somewhere. I'll try to check it out tomorrow.

I'm wearing my compression sock sleeve. Went shopping today and plain old beige ones are $95. Nothing like exploiting the suffering. Anyone know a good online shop with discounts. It's just the principal. I've decided all cancer treatment should be free..

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Aug 8, 2017 05:06PM ksusan wrote:

I agree!

Have you tried Lymphedivas? lymphedivas.com/ You'll need to be sure the compression is adequate for your needs--although it's rated the same, the LE therapists tell me to use a different brand when I'm on an airplane.

Mutant uprising quashed. Dx 1/2015, IDC, Right, Stage IIA, 1/1 nodes, ER+/PR+, HER2- Dx 1/2015, DCIS, Left, Stage 0, Grade 3, 0/2 nodes Hormonal Therapy Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Surgery Lymph node removal: Sentinel; Mastectomy: Left, Right Radiation Therapy Whole-breast Chemotherapy Cytoxan (cyclophosphamide), Taxotere (docetaxel)
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Aug 8, 2017 06:01PM marijen wrote:

I found one at www.compressionproducts.com $47.99 - free fast shipping. I'll work my way up to the expensive fancy ones. Just hope it fits! (my beginner sleeve)

SickTired

I should have had more help last year. Now PT tells me the proteins in the lymph expand the tissues and then it's hard to get them down. To look at me you would never know I have LE so I feel fairly lucky. But it hurts and it's numb and annoying. The proteins are not the same as the ones in our food. It reminds me of the expanding fat and replicating fat cells. Oh well, better late than never.

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Aug 8, 2017 06:11PM Kicks wrote:

If you go to www.jigidi.com (it's a jigsaw puzzle site that I go to a lot), there is an advertiser there that shows compression garments.

Dx 8/7/2009, IBC, Stage IIIC, 19/19 nodes, ER+/PR-, HER2- Chemotherapy 8/24/2009 AC Surgery 10/20/2009 Lymph node removal: Right; Mastectomy: Right Chemotherapy 11/10/2009 Taxol (paclitaxel) Radiation Therapy 2/3/2010 Breast, Lymph nodes
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Aug 8, 2017 07:44PM marijen wrote:

Thanks Kicks, will do. I do like the way compression squeezes the tissues.

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Aug 20, 2017 11:29PM Faith-840 wrote:

ksusan, can I ask what brand of sleeve your LE specialist recommends for use on an airplane. Do you know why she recommends a different brand? We are going to fly to Europe at the end of September and I'm getting worried. I have mild LE that I can usually keep under control but I'm worried about the long flight.

I would also like to find the one infused with aloe as the one I have gets very itchy, especially around the top where those silicone nubs are. I have a tough time keeping it on more than 5-6 hours and that's not long enough for a trip to Europe. I really need to find something different than what I have.

Faith Dx 1/1991, Left, Stage IIIB, 8/26 nodes, ER+/PR+, HER2- Surgery 1/4/1991 Lumpectomy: Left Surgery 2/4/1991 Mastectomy: Left Dx 1/2016, ILC, Left, 6cm+, Stage IV, metastasized to lungs, ER+/PR+, HER2- (FISH) Hormonal Therapy 1/22/2016 Femara (letrozole) Targeted Therapy 1/23/2016 Ibrance (palbociclib) Surgery Reconstruction (left): Nipple reconstruction, Nipple tattoo, Silicone implant, Tissue expander placement Chemotherapy CAF Hormonal Therapy Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone)
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Aug 21, 2017 09:21PM - edited Aug 22, 2017 02:59AM by hugz4u

I'm alergic to the silicon dots. My custom sleeve has a band with the silicon threads running thru to keep it up. It seems to be a bit more gentle on my skin. What ever you do dont scratch. It makes it worse. My brand is jobst. (I still need the glue so maybe I should try no band and just use glue.

Also juzo has a sleeve that comes over the shoulder and secures with a chest strap. It's off the shelf but you could probably get custom in flat knit. This juzo iscircular knit and if I really get irritated i put this on for a couple days till itch calms. However even after a few days if I start to rub it Ill get an itchy flare up.

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Aug 28, 2017 06:07PM marijen wrote:

Here's an interesting article...

Science News

from research organizations

Worm infection reveals cross-talk in the lymph nodes
Date:
August 28, 2017
Source:
Ecole Polytechnique Fédérale de Lausanne
Summary:
By studying a worm infection, scientists have discovered how lymphatic vessels grow within lymph nodes, with major implications for cancer and inflammation.
Share:

FULL STORY

Heligmosomoides polygyrus (a nematode) was used as a gastrointestinal parasitic model to understand the mechanism behind lymph node lymphangiogenesis.

Credit: Lalit Kumar Dubey/EPFL

Heligmosomoides polygyrus (a nematode) was used as a gastrointestinal parasitic model to understand the mechanism behind lymph node lymphangiogenesis.

Credit: Lalit Kumar Dubey/EPFL


Lymph nodes are small, kidney-shaped organs found throughout the body. Full of immune cells, their function is to clear out foreign objects and support the immune system. Lymph nodes communicate with the tissues and with each other through the lymphatic vessels, which carry fluids and objects from the tissues and back out to the bloodstream. Normally, lymphatic vessels grow during the embryo stage, but also in adults during wound healing, cancer, and inflammation. But the exact mechanism of this "lymphangiogenesis" is yet unknown. EPFL scientists have now identified the molecules that signal the growth of lymphatic vessels during worm infections. The work is published in Nature Communications.


The lymphatic vessels drain pathogens from tissues to the collecting lymph nodes, where immune responses begin. They also allow lymphocytes and dendritic cells -- which expose pathogen material to trigger the immune system -- to flow in and out of the lymph nodes. Because of this, lymphangiogenesis is important for immune responses against infections.

But recent studies have shown that lymphangiogenesis can also regulate immune responses during inflammation. This connection between inflammation and lymphangiogenesis is key in our understanding of the adaptive immune response, which is the slower but more specialized wave against infections and involves T and B cells.

The lab of Nicola Harris at EPFL looked at the mesenteric lymph node, which collects fluids and objects from the intestine of mice. The research, led by Lalit Kumar Dubey, follows a 2016 paper from the group, which showed how worm infection stimulates B cells to 'talk' to the endothelial cells of the mesenteric lymph node and kickstart an immune response.

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Sep 15, 2017 07:09AM marijen wrote:

Send to JAMA. 2017 Sep 12;318(10):918-926. doi: 10.1001/jama.2017.11470. Effect of Axillary Dissection vs No Axillary Dissection on 10-Year Overall Survival Among Women With Invasive Breast Cancer and Sentinel Node Metastasis: The ACOSOG Z0011 (Alliance) Randomized Clinical Trial.

Giuliano AE1, Ballman KV2, McCall L3, Beitsch PD4, Brennan MB5, Kelemen PR6, Ollila DW7, Hansen NM8, Whitworth PW9, Blumencranz PW10, Leitch AM11, Saha S12, Hunt KK13, Morrow M14.

Author information Abstract IMPORTANCE:

The results of the American College of Surgeons Oncology Group Z0011 (ACOSOG Z0011) trial were first reported in 2005 with a median follow-up of 6.3 years. Longer follow-up was necessary because the majority of the patients had estrogen receptor-positive tumors that may recur later in the disease course (the ACOSOG is now part of the Alliance for Clinical Trials in Oncology).

OBJECTIVE:

To determine whether the 10-year overall survival of patients with sentinel lymph node metastases treated with breast-conserving therapy and sentinel lymph node dissection (SLND) alone without axillary lymph node dissection (ALND) is noninferior to that of women treated with axillary dissection.

DESIGN, SETTING, AND PARTICIPANTS:

The ACOSOG Z0011 phase 3 randomized clinical trial enrolled patients from May 1999 to December 2004 at 115 sites (both academic and community medical centers). The last date of follow-up was September 29, 2015, in the ACOSOG Z0011 (Alliance) trial. Eligible patients were women with clinical T1 or T2 invasive breast cancer, no palpable axillary adenopathy, and 1 or 2 sentinel lymph nodes containing metastases.

INTERVENTIONS:

All patients had planned lumpectomy, planned tangential whole-breast irradiation, and adjuvant systemic therapy. Third-field radiation was prohibited.

MAIN OUTCOMES AND MEASURES:

The primary outcome was overall survival with a noninferiority hazard ratio (HR) margin of 1.3. The secondary outcome was disease-free survival.

RESULTS:

Among 891 women who were randomized (median age, 55 years), 856 (96%) completed the trial (446 in the SLND alone group and 445 in the ALND group). At a median follow-up of 9.3 years (interquartile range, 6.93-10.34 years), the 10-year overall survival was 86.3% in the SLND alone group and 83.6% in the ALND group (HR, 0.85 [1-sided 95% CI, 0-1.16]; noninferiority P = .02). The 10-year disease-free survival was 80.2% in the SLND alone group and 78.2% in the ALND group (HR, 0.85 [95% CI, 0.62-1.17]; P = .32). Between year 5 and year 10, 1 regional recurrence was seen in the SLND alone group vs none in the ALND group. Ten-year regional recurrence did not differ significantly between the 2 groups.

CONCLUSIONS AND RELEVANCE:

Among women with T1 or T2 invasive primary breast cancer, no palpable axillary adenopathy, and 1 or 2 sentinel lymph nodes containing metastases, 10-year overall survival for patients treated with sentinel lymph node dissection alone was noninferior to overall survival for those treated with axillary lymph node dissection. These findings do not support routine use of axillary lymph node dissection in this patient population based on 10-year outcomes.

TRIAL REGISTRATION:

clinicaltrials.gov Identifier: NCT00003855.

PMID:
28898379
DOI:
10.1001/jama.2017.11470

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