Diagnóstico oftalmológico del síndrome de linfedema-distiquiasis a través de la mutación FOXC2 / Ophthalmologic diagnosis of lymphedema-distichiasis syndrome through the FOXC2 mutation

El síndrome de linfedema-distiquiasis es uno de los fenotipos más frecuentes de aparición de linfedema primario; aun así, su prevalencia es baja.Este síndrome cursa con la aparición en la infancia o en la pubertad de pestañas aberrantes y otras formas de distiquiasis que pueden disminuir la calidad de vida, especialmente en pacientes en edades tan tempranas. La valoración clínica de este tipo de signos debe hacernos tener en mente este grupo de síndromes, ya que contamos, en este caso, con el diagnóstico de certeza gracias al análisis genético en suero del gen FOXC2, como ocurre en el caso que presentamos.De esta manera podemos prevenir, diagnosticar y tratar tanto los síntomas oftalmológicos como el resto de los síntomas sistémicos de forma precoz y más efectiva, aumentando así la calidad de vida de nuestros pacientes. (AU)

Lymphedema-distichiasis syndrome is one of the most frequent phenotypes of primary lymphedema, even so, its prevalence is still low.This syndrome courses with the appearance of abnormal eyelashes and distichiasis during childhood or puberty. This can cause a notable discomfort on our patients, especially at such an early age. The clinic evaluation of this signs must make us have in mind this group of syndromes, because in the case of lymphedema distichiasis syndrome, we can certainly diagnose it with the genetic analysis of the FOXC2 gen on patient's serum.With this we could prevent, diagnose and treat the ophthalmologic syndrome alongside the rest of systemic symptoms of this syndrome in a more effective way, giving our patients a higher quality of life. (AU)

Ophtalmologic diagnosis of lymphedema-distichiasis syndrome through the FOXC2 mutation.

Lymphedema distichiasis syndrome is one of the most frequent phenotypes of primary lymphedema, even so, its prevalence is still low. This syndrome courses with the appearance of abnormal eyelashes and distichiasis during childhood or puberty. This can cause a notable discomfort on our patients, especially at such an early age. The clinic evaluation of this signs must make us have in mind this group of syndromes, because in the case of lymphedema distichiasis syndrome, we can certainly diagnose it with the genetic analysis of the FOXC2 gen on patient's serum. With this we could prevent, diagnose and treat the ophthalmologic syndrome alongside the rest of systemic symptoms of this syndrome in a more effective way, giving our patients a higher quality of life.

Autogestão ineficaz de linfedema em mulheres mastectomizadas: análise de conceito / Autogestión ineficaz de linfedema en mujeres mastectomizadas: análisis de concepto / Ineffective self-management of lymphedema in mastectomized women: concept analysis

Resumo Objetivo Analisar o conceito de "autogestão ineficaz do linfedema" em mulheres mastectomizadas. Métodos Trata-se de uma análise do conceito proposto por Walker e Avant operacionalizada por meio de uma revisão integrativa da literatura, organizada em oito etapas e baseada nas seguintes questões norteadoras: Qual é a definição de autogestão ineficaz em mulheres mastectomizadas? Quais os antecedentes, atributos e consequências da autogestão ineficaz em mulheres mastectomizadas? Como a autogestão ineficaz de linfedema tem sido definida no contexto de mulheres que passaram por mastectomia? A busca de artigos foi realizada em cinco bases de dados eletrônicas, sem limite de data, no período de julho de 2022 a fevereiro de 2023. Resultados Foram identificados 30 antecedentes e 19 consequentes; os mais frequentes entre eles foram respectivamente os seguintes: falta de apoio familiar/social e diminuição da qualidade de vida. Os atributos definidores mais frequentemente identificados foram os seguintes: edema, inchaço no braço, sensação de peso no membro, dor, dormência e diminuição da função do membro. Foram ainda elaborados os casos modelo e contrário para auxiliar na decisão sobre o uso do conceito. Conclusão Os conceitos resultantes da análise contribuem para clarificar os termos e o desenvolvimento da linguagem na enfermagem, devendo ser validados por juízes e prática clínica para melhor aplicação na oncologia clínica.

Resumen Objetivo Analizar el concepto de "autogestión ineficaz de linfedema" en mujeres mastectomizadas. Métodos Se trata de un análisis del concepto propuesto por Walker y Avant, realizado mediante una revisión integradora de la literatura, organizado en ocho etapas y basado en las siguientes preguntas orientadoras: ¿Cuál es la definición de autogestión ineficaz en mujeres mastectomizadas? ¿Cuáles son los antecedentes, atributos y consecuencias de la autogestión ineficaz en mujeres mastectomizadas? ¿Cómo se define la autogestión ineficaz de linfedema en el contexto de mujeres que pasaron por una mastectomía? La búsqueda de artículos fue realizada en cinco bases de datos electrónicas, sin límite de fecha, en el período de julio de 2022 a febrero de 2023. Resultados Se identificaron 30 antecedentes y 19 consecuentes. El antecedente más frecuente fue falta de apoyo familiar/social y el consecuente, reducción de la calidad de vida. Los atributos definidores identificados más frecuentemente fueron los siguientes: edema, hinchazón en el brazo, sensación de peso en el miembro, dolor, adormecimiento y reducción de la función del miembro. Además, se elaboraron los casos modelo y contrarios para ayudar en la decisión sobre el uso del concepto. Conclusión Los conceptos resultantes del análisis contribuyen a clarificar los términos y el desarrollo del lenguaje en enfermería y deben ser validados por jueces y práctica clínica para una mejor aplicación en la oncología clínica.

Abstract Objective To analyze the concept of "ineffective self-management of lymphedema" in mastectomized women. Methods This is an analysis of the concept proposed by Walker and Avant, operationalized through an integrative literature review, organized into eight stages, and based on the following guiding questions: What is the definition of ineffective self-management in mastectomized women? What are the antecedents, attributes, and consequences of ineffective self-management in mastectomized women? How has ineffective self-management of lymphedema been defined in the context of women who have undergone mastectomy? The search for articles was carried out in five electronic databases, with no date limit, from July 2022 to February 2023. Results Antecedents (30) and consequents (19) were identified. Among them, the most frequent were the following, respectively: lack of family and/or social support and decreased quality of life. The most frequently identified defining attributes were the following: edema, swelling in the arm, feeling of heaviness in the limb, pain, numbness, and reduced function of the limb. Model and contrary cases were also designed to help decide on the use of the concept. Conclusion The concepts resulting from the analysis contribute to clarifying the terms and development of language in nursing, and should be validated by judges and clinical practice for better application in clinical oncology.

Prevención quirúrgica del linfedema del miembro superior relacionado con la cirugía axilar en el cáncer de mama / Surgical prevention of upper limb lymphoedema related to axillary surgery in breast cancer

El linfedema (LE) es una de las secuelas más graves e incapacitantes secundarias al tratamiento en el cáncer de mama debido a las limitaciones funcionales, implicaciones estéticas y riesgo de infección que conlleva. Se estima que entre el 29 y 39% de las pacientes que se sujetan a una linfadenectomía axilar desarrollan LE, frente a entre 5 y 7% de los que casos que se realiza una biopsia selectiva de ganglio centinela. Para intentar reducir su incidencia, se ha desarrollado el mapeo axilar inverso. El objetivo de esta técnica es diferenciar las distintas vías de drenaje linfático axilar y del brazo mediante la inyección de un colorante azul en el brazo ipsilateral, para poder respetar los linfáticos que drenan la extremidad superior durante la disección linfática axilar. Otra posibilidad es usar verde de indocianina y así combinar el procedimiento de mapeo axilar inverso con el trazador dual estándar en la biopsia selectiva de ganglio centinela. Gracias a la microcirugía se han desarrollado técnicas como la anastomosis linfático-venosa para la prevención secundaria de LE, de manera que los linfáticos aferentes del brazo se pueden redirigir a ramas colaterales de la vena axilar para restaurar el flujo linfático fisiológico. Este procedimiento es más eficaz en las etapas precoces de LE. En los últimos años se está llevando a cabo la técnica LYMPHA, que consiste en anastomosar los vasos linfáticos del brazo a una rama colateral de la vena axilar en el momento de la disección ganglionar. Esta se ha demostrado útil en la prevención primaria de LE y en la reducción de complicaciones tempranas. (AU)

Lymphoedema (LE) is one of the most serious and disabling sequelae secondary to breast cancer treatment due to the functional limitations, cosmetic implications and risk of infection it entails. Twenty-nine to thirty-nine per cent of patients who undergo axillary lymphadenectomy (AL) are estimated to develop LE, compared to 5-7% in those who undergo selective sentinel lymph node biopsy (SLNB). In an attempt to reduce its incidence, Reverse Axillary Mapping (ARM) has been developed. The aim of this technique is to differentiate the different axillary and arm lymphatic drainage pathways by injecting a blue dye into the ipsilateral arm, in order to respect the lymphatics draining the upper extremity during axillary lymphatic dissection. Another possibility is to use indocyanine green and thus combine the ARM procedure with the standard dual tracer in SLNB. Thanks to microsurgery, techniques such as lymphatic-venous anastomosis (LVA) have been developed for secondary prevention of lymphoedema, so that afferent lymphatics in the arm can be redirected to collateral branches of the axillary vein to restore physiological lymphatic flow. In recent years, the LYMPHA technique, which involves anastomosing the lymphatic vessels of the arm to a collateral branch of the axillary vein at the time of lymph node dissection, has been implemented. This has been shown to be useful in the primary prevention of LE and in the reduction of early complications. (AU)

Validez y fiabilidad del cuestionario DASH en mujeres con linfedema secundario a tratamiento de cáncer de mama / Validity and reliability of DASH questionnaire in women who suffer from lymphedema as a side effect of a breast cancer treatment

Introducción: El cuestionario DASH está diseñado para la valoración funcional del miembro superior en enfermedad musculoesquelética. El objetivo de este trabajo es verificar las principales propiedades instrumentales (validez y fiabilidad) del cuestionario para su aplicación en mujeres españolas con linfedema secundario a tratamiento de cáncer de mama. Métodos: Cohorte prospectiva de 65 mujeres con linfedema secundario a tratamiento de cáncer de mama, en las que se estudió la fiabilidad de la puntuación del DASH mediante la consistencia interna (coeficiente alfa de Cronbach) y test-retest en un intervalo de 15 días (coeficiente de correlación intraclase), y la validez mediante la correlación con las puntuaciones del SF-36v2 y de la FACT-B+4 (r o τ b de Kendall). Resultados: La consistencia interna y fiabilidad test-retest fueron alfa de Cronbach 0,969 y coeficiente de correlación intraclase 0,861, respectivamente. Existía correlación entre las puntuaciones del DASH y las del SF-36v2, sobre todo con los dominios de función física, dolor corporal y rol físico (r de 0,800, 0,738 y 0,682, respectivamente; p<0,001), y menos con el rol emocional y social. Se correlacionaba con la puntuación FACT-B+4 (r=0,836; p<0,001) y la subescala miembro superior (r=0,816; p<0,001) y no existe correlación con la subescala social/familiar (r=0,193; p=0,216). Conclusión: El cuestionario DASH es una herramienta fiable y válida para ser utilizada en la valoración funcional de miembro superior de mujeres españolas con linfedema secundario a tratamiento de cáncer de mama.(AU)

Introduction: DASH questionnaire was designed to assess upper limb function in musculoskeletal pathologies. The aim of this manuscript is to study the reliability and validity of this questionnaire, to determine if is adequate to use in women with lymphedema due to breast cancer treatment. Methods: Prospective study in 65 women with lymphedema due to breast cancer treatment was done, in which the reliability of DASH score with internal consistency (Cronbach's alpha) and test–retest reproducibility 15 days’ interval (interclass correlation coefficient) and validity by correlation with SF-36v2 and FACT-B+4 (r or Kendall's τ b) scores was investigated. Results: The internal consistency and the test–retest were Cronbach's alpha 0.969 and interclass correlation coefficient 0.861, respectively. There was correlation between the DASH score with the SF-36v2 score, mainly in the areas of physical function, body pain and physical role (r 0.800, 0.738, and 0.682, respectively; p<0.001), and lowest with the emotional and social wellbeing. The DASH score had correlation with FACT-B+4 (0.836; p<0.001) and the subscales the upper limb score (r=0.816; p<0.001), and there was no correlation with the social/familiar subscale (r=0.193; p=0.216). Conclusion: The DASH questionnaire is a reliable and valid tool to assess upper limb functionality in Spanish women with breast cancer related lymphedema.(AU)

Indirect partial volumetry in breast cancer-related lymphoedema: Distribution of oedema and clinical-diagnostic implications / Volumetría parcial indirecta en linfedema relacionado con cáncer de mama: distribución del edema e implicaciones clínico-diagnósticas

Introduction and objectives: Currently, the assessment of lymphoedema related to breast cancer (BCRL) is performed through the global perimeter volumetry. We implemented an additional system with partial measures (hand, forearm, and upper arm) that allows us to approximate the segmental distribution of oedema. We used this measurement tool to determine the oedema distribution and its evolution, as well as its possible impact on clinical assessment. Methods: We carried out a retrospective observational study of the patients referred to our service with suspected BCRL. Inclusion criteria: Unilateral breast cancer, availability of global and partial digital medical record, and follow-up for a minimum of 24 months. Of the 210 selected patients, 190 were considered affected (≥10% excess volume). We analysed at three time points (initial, final, and peak involvement) the oedema distribution and segmental predominance and its relationship with the evolutionary course and the severity of the process. We subsequently examined, at the initial timepoint, the concordance of the global assessment with the partial assessment for the clinical classification of the 210 patients in the initial sample. Results: The BCRL oedema was characteristically irregular, with the forearm being the most affected segment and the hand the least affected (RM ANOVA: p<0.001). The irregularity was related to its severity (χ2: p<0.001) and the evolutionary course (Student t-test: p<0.005 for the hand). Overall, disagreement of 46.67% was observed between the clinical classification of the global and partial assessment. Conclusions: This work supports the need to add partial volumetry to the commonly used global assessment.(AU)

Introducción y objetivos: Actualmente la volumetría perimetral global se utiliza para valorar el linfedema relacionado con cáncer de mama (LRCM). Nosotros implementamos un sistema adicional que permite aproximarse a la distribución segmentaria del edema mediante tres indicadores parciales: mano, antebrazo y brazo. Utilizamos esta herramienta para conocer la distribución del edema, su evolución y su posible repercusión en la valoración clínica. Metodología: Se realizó un estudio observacional retrospectivo de los pacientes remitidos a nuestro servicio con sospecha de LRCM. Criterios de inclusión: Cáncer de mama unilateral, con registros volumétricos en la historia clínica digital y 24 meses de seguimiento mínimo. De los 210 pacientes seleccionados, en 190 pacientes afectos (≥10% de exceso de volumen) se analizaron en tres momentos de medición (inicial, final y máxima afectación) la distribución del edema, su predominio segmentario y la relación con la evolución y la gravedad del proceso. Posteriormente se examinó la concordancia de los indicadores globales con los parciales en la valoración clínica de los 210 pacientes de la muestra inicial. Resultados: El LRCM fue característicamente irregular, siendo el antebrazo el segmento predominante y la mano el menos afecto (MR ANOVA: p<0,001). La irregularidad se relacionó con la gravedad del proceso (chi cuadrado: p<0,001) y su evolución (t de Student: p<0,005 para la mano). Además, se apreció, en conjunto, una discordancia en la valoración clínica del índice global con los índices parciales del 46,67% (W de Kendall=0,467). Conclusión: El estudio apoya la necesidad de añadir volumetría parcial a la valoración global habitualmente utilizada.(AU)

Síndrome de las uñas amarillas. Presentación de un caso con estudio autópsico / Yellow nail syndrome. A case report with postmortem study

El síndrome de las uñas amarillas es una enfermedad rara de etiología desconocida, caracterizado por una coloración amarillenta de las uñas, manifestaciones respiratorias y linfedemas primarios1. Existe poca literatura científica en referencia a estudios autópsicos de pacientes con este síndrome, así como respecto a su etiología, si bien se postula que es causada por una malformación de los conductos linfáticos. En este artículo presentamos el caso de una paciente diagnosticada en vida de síndrome de las uñas amarillas en cuyo estudio autópsico se encontraron algunos hallazgos previamente no descritos, como dilatación de los senos de ganglios linfáticos mediastinales y esplénicos.(AU)

Yellow nail syndrome is a rare disease of unknown aetiology. Patients with YNS have a characteristic yellowish-coloured nails, pulmonary alterations and primary lymphedema. To the best of our knowledge, only a few reports of autopsy findings in these patients have been published. Its aetiology possibly involves a primary malformation of larger lymph vessels. We describe autopsy findings not previously associated with yellow nail syndrome, such as expansion of mediastinal lymph-nodes and splenic sinusoids.The present autopsy reveals hitherto unreported findings associated with YNS, such as alterations in splenic sinusoids and mediastinal lymph-node sinuses.(AU)

Aplicativo para tratamento do linfedema de membros superiores / Upper limb lymphedema treatment application

Introdução: O linfedema secundário se desenvolve comumente devido a um trauma no sistema linfático, podendo ocorrer após cirurgia de câncer. O aplicativo móvel é um meio de atualização técnico-científica de fácil acesso e de baixo custo que pode auxiliar o profissional de saúde a proporcionar o melhor tratamento para o paciente. O objetivo desse estudo foi construir um aplicativo para tratamento de linfedema de membros superiores. Método: A construção do aplicativo ocorreu em quatro etapas: (1) Concepção, envolvendo a identificação das necessidades do desenvolvimento do aplicativo; (2) Elaboração do conteúdo, incluindo a revisão integrativa da literatura nas principais bases de dados; (3) Construção, consistindo na estruturação do banco de dados e desenvolvimento do software; e (4) Transição, compreendendo a realização de testes de funcionalidade. Resultados: O aplicativo desenvolvido (Linfedema APP) é composto por 31 telas, 4 figuras e 3 vídeos. Ele foi registrado no Instituto Nacional da Propriedade Industrial (INPI) do Ministério do Desenvolvimento, Indústria e Comércio Exterior e está disponível gratuitamente na Google Play Store. Conclusão: Após a revisão integrativa da literatura nas principais bases de dados, foi desenvolvido o aplicativo "Linfedema APP", o qual se constitui em ferramenta prática para qualificar, direcionar e guiar o fisioterapeuta na realização dos exercícios nas pacientes pós- mastectomizados com linfedema em membros superiores.

Introduction: Secondary lymphedema commonly develops due to trauma to the lymphatic system, and may occur after cancer surgery. The mobile application is an easily accessible and low-cost means of technical-scientific updating that can help the health professional to provide the best treatment for the patient. Thus, the objective of this study was to build an application for the treatment and prevention of upper limb lymphedema. Methods: The construction of the application took place in four stages: (1) Conception, involving the identification of application development needs; Content development, including an integrative literature review in the main databases; (3) Construction, consisting of structuring the database and developing the software; and (4) Transition, comprising carrying out functionality tests. Results: The developed application (Linfedema APP) consists of 31 screens, 4 figures and 3 videos. It was registered at the National Institute of Industrial Property (INPI) of the Ministry of Development, Industry and Foreign Trade, and is available for free on the Google Play Store. Conclusion: After an integrative review of the literature in the main databases, the "Lymphedema APP" application was developed, which constitutes a practical tool to qualify, direct and guide the physiotherapist in performing the exercises in post-mastectomized patients with lymphedema in the upper limbs.

Linfedema escrotal gigante / Giant scrotal lymphedema

RESUMEN La elefantiasis escrotal es una condición que ha sido históricamente descripta en áreas endémicas de filariasis, pero es menos frecuente su presentación idiopática o asociada a otras entidades. Presentamos un caso de elefantiasis escrotal gigante de causa adquirida idiopática, al que se le practicó la exéresis de la estructura linfedematosa y la reconstrucción del defecto con colgajos locales y autoinjerto cutáneo. El motivo de su divulgación radica en que se trata de un caso muy poco frecuente, ya sea por la baja incidencia y etiología, así como por la importante magnitud del problema para el individuo. El objetivo principal en el tratamiento del linfedema, en el caso presentado, fue devolverle al paciente funciones primarias y elementales de vida, además de disminuir la morbilidad y otorgarle una mejor calidad de vida.

ABSTRACT Scrotal elephantiasis is a condition that has been historically described in areas where filariasis is endemic, but idiopathic cases or those associated with other entities are rare. We report a case of a patient with idiopathic acquired giant scrotal elephantiasis who underwent excision of the lymphedematous structure and reconstruction of the defect with local flaps and skin autograft. The reason for this presentation is the uncommon nature of the case due to its low incidence, rare etiology and the magnitude of the problem experienced by the patient. The main goal in the treatment of lymphedema in this case was to restore primary and elementary functions of life to the patient, reduce morbidity and provide him with a better quality of life.

[Yellow nail syndrome. A case report with postmortem study]. / Síndrome de las uñas amarillas. Presentación de un caso con estudio autópsico.

Yellow nail syndrome is a rare disease of unknown aetiology. Patients with YNS have a characteristic yellowish-coloured nails, pulmonary alterations and primary lymphedema. To the best of our knowledge, only a few reports of autopsy findings in these patients have been published. Its aetiology possibly involves a primary malformation of larger lymph vessels. We describe autopsy findings not previously associated with yellow nail syndrome, such as expansion of mediastinal lymph-nodes and splenic sinusoids. The present autopsy reveals hitherto unreported findings associated with YNS, such as alterations in splenic sinusoids and mediastinal lymph-node sinuses.

Role of weight lost in breast cancer-related lymph / Importancia de la pérdida de peso en el linfedema secundario a cáncer de mama

Objective: Analysis of data collected in routine clinical practice of the combined impact of both physical activity and decrease in body mass index (BMI) on a minor prevalence of lymphedema in post-breast cancer patients. Methods: Analysis of data obtained by the specialized rehabilitation unit, from 99 female patients for 18 months, after a specific diet, sports program and complete decongestive therapy (CDT) was indicated. Personal data, affected organ volume, weight, physical activity level and Functional Assessment of Cancer Therapy Questionnaire for Breast Cancer (FACT-B+4) were collected in follow-up visits. Results: Although the average of body-mass index showed no change during the assessment period, about 13% of patients in the second follow-up visit and 30% in the third one had lost weight. Women experiencing weight-loss in the third follow-up visit presented a reduced volume of the affected organ [−50 (−248 to 141) ml vs. 130 (−148 to 355) ml, p<0.05] as compared to weight-gaining patients. No relationship was established between physical activity and lymphedema volume changes. Conclusions: Apart from the conventional treatment with orthotics and manual lymph drainage, BCRL prevention and treatment needs to focus – right from the start – on weight management or weight-loss in obese patients.(AU)

Objetivo: Analizar los datos recopilados en la práctica clínica rutinaria sobre el impacto combinado de la actividad física y la reducción del índice de masa corporal (IMC) en la reducción de la prevalencia de linfedema secundario a cáncer de mama (BCRL). Métodos: Análisis de los datos obtenidos por la unidad de rehabilitación especializada, de 99 pacientes durante 18 meses, tras prescribirse una dieta específica, un programa deportivo y una terapia descongestiva completa (TDC). En las visitas de seguimiento se recopilaron datos personales, volumen del órgano afectado, peso, nivel de actividad física y FACT-B+4 (Functional Assessment of Cancer Therapy Questionnaire for Breast Cancer). Resultados: Aunque el índice de masa corporal medio no reflejó cambios durante el periodo de evaluación, cerca del 13% de las pacientes habían perdido peso en la segunda semana de seguimiento, incrementándose este porcentaje al 30% en la tercera semana. Las mujeres que experimentaron pérdida de peso durante la tercera visita de seguimiento presentaron una reducción del volumen del órgano afectado [-50 (-248-141)ml vs. 130 (-148-355)ml, p<0,05] en comparación con las pacientes que habían ganado peso. No se estableció relación alguna entre la actividad física y los cambios de volumen de linfedema. Conclusiones: Aparte del tratamiento convencional con ortésicos y drenaje linfático manual, la prevención y tratamiento de BCRL debe centrarse, desde el inicio, en la gestión del peso o la pérdida de peso en las pacientes obesas.(AU)

Efectividad de la fisioterapia multimodal acuática mediante ejercicio terapéutico, autodrenaje manual y medidas de autocuidado en el linfedema de miembro superior en mujeres supervivientes de cáncer de mama. Ensayo clínico aleatorizado / Effectiveness of aquatic multimodal physiotherapy through therapeutic exercise, manual self-drainage and self-care measures in upper limb lymphedema in female breast cancer survivors. Randomized clinical trial

Introducción El linfedema secundario al cáncer de mama es una patología crónica. La fisioterapia descongestiva compleja (FDC) es el tratamiento conservador de elección, consta de una fase intensiva para disminuir el volumen de la extremidad, y una fase de mantenimiento para fomentar el autocontrol de la patología. El objetivo es evaluar si la fisioterapia multimodal acuática (FMA) compuesta por ejercicio terapéutico, auto drenaje manual y medidas de autocuidado de miembro superior mantiene o reduce el volumen del linfedema en fase de mantenimiento y si esta es más efectiva que la fisioterapia multimodal de miembro superior en sala. Metodología Se ha realizado un ensayo clínico aleatorizado comparando dos grupos, experimental n:43 que realizó una pauta de ejercicios en el medio acuático y control n:47 que realizó la misma pauta de ejercicios en sala. Ambos grupos efectuaron 20 sesiones de 45 min, dos o tres días por semana. Se evaluaron como variables principales los cambios en el volumen del linfedema, mediante circometría y la calidad de vida de las participantes, mediante la escala FACT-B + 4. Resultados No se encontraron diferencias estadísticamente significativas entre las intervenciones realizadas, ambas mejoran el volumen a las 20 sesiones (p = 0,7855), pero si entre la frecuencia del tratamiento y el tiempo postintervención (p<0,01). Se encontraron mejoras en las variables de calidad de vida; «estado físico general del paciente», «ambiente familiar y social», «estado emocional», «capacidad de funcionamiento personal» y «preocupaciones de las pacientes» (p < 0,01). Conclusión La FMA de miembro superior parece mejorar la calidad de vida de las mujeres supervivientes con linfedema de miembro superior en fase de mantenimiento. La FMA no muestra un beneficio añadido a la fisioterapia multimodal en sala (AU)

Introduction Lymphedema secondary to breast cancer is a chronic pathology. Complex decongestive physiotherapy is the conservative treatment of choice, it consists of an intensive phase to minimize the volume of the limb, and a maintenance phase to promote self-control of the pathology. The objective is to evaluate if aquatic multimodal physiotherapy (AMP) composed of therapeutic exercise, manual self-drainage and upper limb self-care measures maintains or reduces the volume of lymphedema in the maintenance phase and if it is more effective than upper limb multimodal physiotherapy in-room. Methodology A randomized clinical trial has been carried out comparing two groups, experimental N:43 that performed a pattern of exercises in an aquatic environment and control N:47 that performed the same pattern of exercises in-room. Both groups carried out 20 sessions of 45min, 2 or 3 days per week. The main variables were the changes in the volume of the lymphedema, by means of circometry, and the quality of life of the participants, by means of the FACT-B + 4 scale. Results No statistically significant differences were found between the interventions carried out, both improve the volume at 20 sessions (p = 0.7855), the interaction between the frequency of treatment and the time after intervention was (p-value: < 0.01). Improvements were found in quality of life variables; «general physical state of the patient», «family and social environment», «emotional state», «personal functioning capacity» and «patient concerns» (p-value: < 0.01). Conclusion Upper limb AMP seems to improve the quality of life of surviving women with upper limb lymphedema in the maintenance phase. AMP does not show an added benefit to room multimodal physiotherapy (AU)

Outcomes and bioethical implications of lymphadenectomy in mastectomized patients: Importance and indication of ultrasound-guided fine-needle aspiration biopsy / Resultados e implicaciones bioéticas de la linfadenectomía en pacientes mastectomizadas: Importancia y recomendación de biopsia por aspiración con aguja fina guiada por ecografía / Resultados e implicações bioéticas da linfadenectomia em pacientes mastectomizadas: Importância e recomendação da biópsia aspirativa com agulha fina guiada por ultrassom

Introduction: Lymph node involvement is the main prognostic factor in breast cancer. Mastectomized patients usually undergo lymphadenectomy (LA) of micrometastatic sentinel lymph nodes (SLNs) despite the evidence of AMAROS trial to replace this therapy with radiotherapy in select cases. Objective: Demonstrate the ability of ultrasonography to detect non-metastatic or micrometastatic SLNs. Materials and methods: 132 patients who underwent mastectomy were evaluated. Ultrasound-guided fine-needle aspiration biopsy (FNAB) was indicated for suspicious lymph nodes. LA and SNL biopsy (SLNB) were performed in patients with positive and negative FNAB, respectively. LA was performed in FNAB positive or SLNB positive cases, except in the presence of isolated tumor cells and micrometastatic SLNs. The tumor burden after LA in patients with negative FNAB and positive SLNB was measured; the presence of two or fewer positive SLNs was considered a low burden. Results: Sensitivity of FNAB for detecting positive lymph nodes in patients with a high tumor burden was 93% and specificity was 84%. Positive (PPV) and negative predictive value (NPV) were 60% and 79%, respectively. Conclusions: LA could have been avoided in 90% of mastectomized patients with negative FNAB and a low tumor burden who met the AMAROS criteria with a high NPV (79%).

Introducción: La afectación ganglionar es el principal factor pronóstico en cáncer de seno. Generalmente, pacientes mastectomizadas se somenten a linfadenectomia (LA) de ganglios linfáticos centinela micrometastásicos (GLCs), a pesar de la evidencia del ensayo AMAROS en ciertos casos para reemplazarla con radioterapia. Objetivo: Demostrar la importancia de la ecografía para detectar GLCs no metastásicos o micrometastásicos. Materiales y métodos: Se evaluaron132 pacientes sometidas a mastectomía. Se recomendó biopsia aspirativa con aguja fina (BAAF) por ultrasonido para ganglios linfáticos sospechosos. Se realizó Biopsia LA y biopsia de GLCs (BGLC) en pacientes con BAAF positiva y negativa, respectivamente. En casos positivos de BAAF o BGLC se ejecutó LA, excepto en presencia de células tumorales aisladas y GLCs. Se evaluó la carga tumoral posterior a LA en pacientes con BAAF negativa y BGLC positiva. La presencia de dos o menos GLC positivos se consideró carga baja. Resultados: La sensibilidad de BAAF para detectar nódulos linfáticos positivos en pacientes con alta carga tumoral fue del 93%; la especificidad fue del 79%. Valores predictivos positivo (60%) y negativo (79%). Conclusiones: Se podría haber evitado LA en 90% de pacientes mastectomizadas con BAAF negativa y baja carga tumoral que cumplían criterios AMAROS con alto VPN (79%).

Introdução: O comprometimento dos gânglios é o principal fator prognóstico no câncer de mama. Geralmente, pacientes mastectomizadas são submetidas a linfadenectomia (LA) de gânglios linfáticos sentinelas de micrometástases (GLSs), apesar da evidência do estudo AMAROS em certos casos para substituí-la por radioterapia. Objetivo: Demonstrar a importância da ultrassonografia na detecção de GLSs não metastáticos ou micrometástase. Materiais e métodos: Foram avaliadas 132 pacientes submetidas à mastectomia. A biópsia aspirativa com agulha fina (BAAF) ultrassônica foi recomendada para gânglios linfáticos suspeitos. A biópsia LA e a biópsia do GLSs (BGLS) foram realizadas em pacientes com BAAF positivo e negativo, respectivamente. Nos casos positivos de BAAF ou BGLS, a LA foi realizada, exceto na presença de células tumorais isoladas e GLSs. A carga tumoral após a LA foi avaliada em pacientes com BAAF negativa e BGLS positiva. A presença de dois ou menos GLS positivos foi considerada carga baixa. Resultados: A sensibilidade do BAAF para detectar linfonodos positivos em pacientes com alta carga tumoral foi de 93%; a especificidade foi de 79%. Valores preditivos positivos (60%) e negativos (79%). Conclusões: a LA poderia ter sido evitada em 90% das pacientes mastectomizadas com BAAF negativa e baixa carga tumoral que preencheram os critérios AMAROS com alto VPN (79%).

Drenaje linfático subcutáneo (linfocentesis) de la extremidad superior en el linfedema relacionado con el cáncer de mama. A propósito de un caso / Subcutaneous lymphatic drainage (lymphocentesis) of the upper limb in breast cancer - related lymphedema. A propose of a case

El edema es el resultado de un desequilibrio entre la filtración capilar y el drenaje linfático del espacio intersticial; el edema no linfático se produce como resultado de un cambio en la permeabilidad de las paredes capilares y, como consecuencia, se origina un cambio de gradiente entre las presiones hidrostáticas de los vasos sanguíneos y los tejidos; en cambio, el linfedema se refiere a que el edema es causado por daño linfático, en todos los casos de edema crónico habrá alguna alteración del drenaje linfático, ya sea por una anormalidad subyacente (primaria o secundaria), ya sea por “falla linfática” debido a sobrecarga linfática. El grado de daño linfático influye en la presentación clínica del edema; con el tiempo, el componente líquido del edema puede ser sustituido por fibrosis y/o tejido adiposo. El linfedema de las extremidades es una de las enfermedades más difíciles de manejar en medicina paliativa. Un estudio retrospectivo reciente reveló que el 46 % de los edemas eran de tipo mixto (linfático y no linfático), el 29 % eran linfedema y el 10 % eran edemas no relacionados con el sistema linfático. En la mayoría de los casos es una consecuencia de las enfermedades malignas y sus tratamientos, y supone una enorme pérdida de calidad de vida. Cuando fallan las técnicas de drenaje por compresión y la compresión con medias, se puede intentar el drenaje subcutáneo. Hay pocos informes con diversas técnicas de drenaje subcutáneo, con inserción de catéteres simples o múltiples, diferentes modos de recogida de líquido, sobre todo en las extremidades inferiores con variación en la tasa de éxito. (AU)

Edema is the result of an imbalance between capillary filtration and lymphatic drainage of the interstitial space; non-lymphatic edema occurs as a result of change in the permeability of capillary walls, resulting in change in the gradient between the hydrostatic pressures of the blood vessels and tissues, whereas lymphedema refers to edema being caused by lymphatic damage; in all cases of chronic edema there will be some impairment of lymphatic drainage, either by an underlying abnormality (primary or secondary) or by “lymphatic failure” due to lymphatic overload. The degree of lymphatic damage influences the clinical presentation of edema; over time, the fluid component of edema may be replaced with fibrosis and/or adipose tissue. Lymphedema of the extremities is one of the most difficult diseases to manage in palliative medicine. A recent retrospective study revealed that 46 % of edema cases were of mixed type (lymphatic and non-lymphatic), 29 % were lymphedema cases, and 10 % were non-lymphatic edema cases. In most cases it is a consequence of malignant diseases and their treatments, and represents an enormous loss of quality of life. When compression drainage and compression stocking techniques fail, subcutaneous drainage may be attempted. There are few reports with various subcutaneous drainage techniques, with insertion of single or multiple catheters, different modes of fluid collection, especially in the lower extremities, with variation in success rate. (AU)

Indirect partial volumetry in breast cancer-related lymphoedema: Distribution of oedema and clinical-diagnostic implications.

INTRODUCTION AND OBJECTIVES: Currently, the assessment of lymphoedema related to breast cancer (BCRL) is performed through the global perimeter volumetry. We implemented an additional system with partial measures (hand, forearm, and upper arm) that allows us to approximate the segmental distribution of oedema. We used this measurement tool to determine the oedema distribution and its evolution, as well as its possible impact on clinical assessment. METHODS: We carried out a retrospective observational study of the patients referred to our service with suspected BCRL. INCLUSION CRITERIA: Unilateral breast cancer, availability of global and partial digital medical record, and follow-up for a minimum of 24 months. Of the 210 selected patients, 190 were considered affected (≥10% excess volume). We analysed at three time points (initial, final, and peak involvement) the oedema distribution and segmental predominance and its relationship with the evolutionary course and the severity of the process. We subsequently examined, at the initial timepoint, the concordance of the global assessment with the partial assessment for the clinical classification of the 210 patients in the initial sample. RESULTS: The BCRL oedema was characteristically irregular, with the forearm being the most affected segment and the hand the least affected (RM ANOVA: p<0.001). The irregularity was related to its severity (χ2: p<0.001) and the evolutionary course (Student t-test: p<0.005 for the hand). Overall, disagreement of 46.67% was observed between the clinical classification of the global and partial assessment. CONCLUSIONS: This work supports the need to add partial volumetry to the commonly used global assessment.

[Validity and reliability of DASH questionnaire in women who suffer from lymphedema as a side effect of a breast cancer treatment]. / Validez y fiabilidad del cuestionario DASH en mujeres con linfedema secundario a tratamiento de cáncer de mama.

INTRODUCTION: DASH questionnaire was designed to assess upper limb function in musculoskeletal pathologies. The aim of this manuscript is to study the reliability and validity of this questionnaire, to determine if is adequate to use in women with lymphedema due to breast cancer treatment. METHODS: Prospective study in 65 women with lymphedema due to breast cancer treatment was done, in which the reliability of DASH score with internal consistency (Cronbach's alpha) and test-retest reproducibility 15 days' interval (interclass correlation coefficient) and validity by correlation with SF-36v2 and FACT-B+4 (r or Kendall's τ b) scores was investigated. RESULTS: The internal consistency and the test-retest were Cronbach's alpha 0.969 and interclass correlation coefficient 0.861, respectively. There was correlation between the DASH score with the SF-36v2 score, mainly in the areas of physical function, body pain and physical role (r 0.800, 0.738, and 0.682, respectively; p<0.001), and lowest with the emotional and social wellbeing. The DASH score had correlation with FACT-B+4 (0.836; p<0.001) and the subscales the upper limb score (r=0.816; p<0.001), and there was no correlation with the social/familiar subscale (r=0.193; p=0.216). CONCLUSION: The DASH questionnaire is a reliable and valid tool to assess upper limb functionality in Spanish women with breast cancer related lymphedema.

Role of weight lost in breast cancer-related lymph.

OBJECTIVE: Analysis of data collected in routine clinical practice of the combined impact of both physical activity and decrease in body mass index (BMI) on a minor prevalence of lymphedema in post-breast cancer patients. METHODS: Analysis of data obtained by the specialized rehabilitation unit, from 99 female patients for 18 months, after a specific diet, sports program and complete decongestive therapy (CDT) was indicated. Personal data, affected organ volume, weight, physical activity level and Functional Assessment of Cancer Therapy Questionnaire for Breast Cancer (FACT-B+4) were collected in follow-up visits. RESULTS: Although the average of body-mass index showed no change during the assessment period, about 13% of patients in the second follow-up visit and 30% in the third one had lost weight. Women experiencing weight-loss in the third follow-up visit presented a reduced volume of the affected organ [-50 (-248 to 141) ml vs. 130 (-148 to 355) ml, p<0.05] as compared to weight-gaining patients. No relationship was established between physical activity and lymphedema volume changes. CONCLUSIONS: Apart from the conventional treatment with orthotics and manual lymph drainage, BCRL prevention and treatment needs to focus - right from the start - on weight management or weight-loss in obese patients.

A percepção e conduta sobre a medida da pressão arterial em pacientes com neoplasia de mama em cardiologistas e mastologistas / The perception and management of blood pressure measurement in patients with breast cancer in cardiologists and mastologistas

Embora pacientes submetidas ao tratamento cirúrgico para Neoplasia de Mama, de modo geral e frequente, recebam orientações para não medir a pressão arterial no braço homolateral ao seu tratamento, devemos reavaliar contemporaneamente e cientificamente estas recomendações. O propósito deste trabalho é demonstrar os dados de Medicina Baseada em Evidências e considerar a evolução da abordagem cirúrgica neste grupo de pacientes, atualizando estas recomendações e demostram dados de enquete sobre o assunto entre médicos de diferentes especialidades. Há suficiente suporte científico e explicações para que orientemos de forma individualizada e coerentemente estas pacientes em relação a medida da pressão arterial e consequentemente sua relação com o aparecimento do linfedema no braço homolateral, porém a Sociedade Brasileira de Cardiologia, pelo seu Departamento de Hipertensão Arterial não tem recomendações sobre este assunto. Que deve ser contextualizado devido a má percepção sobre o assunto, em repostas a uma enquete feita com Cardiologistas e Mastologistas sobre este tema (AU)

Although patients undergoing surgical treatment for breast cancer are often advised against measuring blood pressure in the arm on the same side as their treatment, it is crucial to reevaluate these recommendations using contemporary and scientific evidence. The objective of this study is to present empirical data on Evidence-Based Medicine and explore the evolving surgical approaches in this patient population. By updating these recommendations and showcasing survey results from physicians across different specialties, we aim to provide comprehensive guidance on the topic. While there is ample scientific support and explanations to individually and coherently guide these patients regarding blood pressure measurement and its potential association with lymphedema in the affected arm, it is important to note that the Brazilian Society of Cardiology, specifically its Department of Arterial Hypertension, does not currently offer recommendations on this matter. This contextualization is necessary due to the limited awareness and understanding of the subject, as revealed through responses obtained from Cardiologists and Mastologists participating in our survey.

Immobilization, Lymphedema, and Obesity are Predictive Factors in the Development of Adhesive Capsulitis in Breast Cancer Patients / Imobilização, linfedema e obesidade são fatores preditivos no desenvolvimento de capsulite adesiva em pacientes com câncer de mama

Abstract Objective Adhesive capsulitis is a condition characterized by shoulder pain and stiffness. Breast cancer treatment has been linked to the development of this condition, but its mechanisms are still little known. This study's objective was to identify predictors factors associated with the development of adhesive capsulitis in breast cancer patients. Methods A case control study was performed with women undergoing treatment for breast cancer in a single center. The sampling was nonprobabilistic and consecutive. Adhesive capsulitis was defined as constant pain associated with decreased active and passive shoulder movement in anterior elevation, external rotation at 0°/90° abduction, and internal rotation at 90° abduction. The study group consisted of patients with shoulder pain and range of motion limitations, while the control group consisted of women without any shoulder abnormalities. Sociodemographic and clinical variables were collected. A univariate logistic regression was used to assess the influence of variables on the studied outcome. For p< 0.20, a multivariate logistic regression was used. The probability of null hypothesis rejection was 5%. Results A total of 145 women were assessed, with 39 (26.9%) on the study group and 106 (73.1%) on the control group. The majority was under 60 years old. In the multivariate analysis, variables correlated to the outcome under study were shoulder immobilization (OR = 3.09; 95% CI: 1.33-7.18; p= 0.009), lymphedema (OR = 5.09; 95% CI: 1.81-14.35; p= 0.002), and obesity (OR = 3.91; 95% CI: 1.27-12.01; p= 0.017). Conclusion Lymphedema, postsurgery immobilization, and obesity are predictive factors for the development of adhesive capsulitis in breast cancer patients.

Resumo Objetivo Capsulite adesiva é uma afecção caracterizada por dor e limitação dos movimentos do ombro. O tratamento do câncer de mama está relacionado ao desenvolvimento dessa doença por meio de mecanismos ainda pouco conhecidos. O objetivo do estudo foi identificar os fatores associados ao desenvolvimento de capsulite adesiva em pacientes com câncer de mama. Métodos Um estudo caso-controle foi realizado com mulheres em tratamento para câncer de mama em um centro único. A amostra foi consecutiva e não-probabilística. A capsulite adesiva foi pré-definida como dor constante e diminuição da amplitude de movimentos em elevação anterior, rotação externa em 0°/90° abdução e rotação interna em 90° abdução. O grupo caso foi constituído por pacientes com dor e limitação de todos os movimentos do ombro, enquanto o controle por pacientes sem qualquer alteração nesta articulação. Variáveis sociodemográficas e clínicas foram coletadas. Foi realizada uma análise de regressão logística univariada para avaliar a influência das variáveis em relação ao desfecho estudado. Para valores de p< 0,20, realizou-se a análise de regressão logística multivariada. A probabilidade de se rejeitar a hipótese nula foi de 5%. Resultados Foram avaliadas 145 mulheres, sendo 39 casos (26,9%) casos e 106 controles (73,1%). Na análise multivariada, as variáveis associadas ao desfecho estudado foram imobilização do ombro (OR = 3,09; 95% IC: 1,33-7,18; p= 0,009), linfedema (OR = 5,09; 95% IC: 1,81-14,35; p= 0,002) e obesidade (OR = 3,91; 95% IC: 1,27-12,01; p= 0,017). Conclusão Linfedema, imobilização pós-cirúrgica e obesidade são fatores preditores associados ao desenvolvimento de capsulite adesiva em pacientes com câncer de mama.