Lymphedema, a chronic swelling condition common in breast cancer survivors, affects three million people in the U.S. In the past, most people believed that exercise might induce or worsen lymphedema. After reviewing the literature, University of Missouri researchers say the benefits of exercise outweigh the risks for breast cancer survivors and patients with lymphedema. Jane Armer, professor in the Sinclair School of Nursing, says patients at risk for lymphedema can exercise if they closely monitor their activities.
"Exercise can be beneficial and not harmful for breast cancer survivors," Armer said. "Each individual should balance the pros and cons of the activity she chooses, but keep in mind that being sedentary has risks and being active is beneficial in many ways, including possibly reducing the risk of cancer recurrence."
Lymphedema can occur any time after cancer treatment and is usually caused by the removal or radiation of lymph nodes as part of the treatment process. Armer found that patients who exercise had no greater risk for developing lymphedema than those who do not exercise. In addition, patients with lymphedema did not worsen their condition by exercising. She says future research is needed to determine whether exercise prevents the condition.
"Breast cancer survivors do not need to restrict their activity as we once thought," Armer said. "If patients want to be active, they should carefully condition their bodies by increasing repetitions of resistance exercises under proper supervision."
In another new literature review, Armer and her colleagues examined published literature pertaining to the surgical treatment of lymphedema. They found that in most studies surgery did not eliminate the need for traditional compression garments in patients with lymphedema.
"Many people think surgery will correct the underlying lymphatic problem, but that is not correct," Armer said. "There are several surgical techniques that may reduce the swelling associated with lymphedema. In most cases, it is recommended that patients undergo traditional therapy using specialized massage and compression garments and bandages to reduce fluid and swelling before considering surgery."
The literature reviews were the first two in a series of thirteen reviews to be published in conjunction with the American Lymphedema Framework Project (ALFP). Established in 2008, the ALFP aims to increase awareness of lymphedema, improve patient care and enhance training for professionals caring for persons at risk or with cancer-related lymphedema. The ALFP has two main goals: maintain up-to-date best practices supported with evidence-based lymphedema treatment guidelines for health practitioners, and create a minimum data set of all available lymphedema research and clinical data.
The first article, "Exercise in patients with lymphedema: A systematic review of the contemporary literature," was published in the Journal of Cancer Survivorship. The second, "The surgical treatment of lymphedema: A systematic review of the contemporary literature," was published in Annals of Surgical Oncology.
Tuesday, 20 November 2012
Sunday, 18 November 2012
Liver Cells, Insulin-Producing Cells, Thymus Can Be Developed in Lymph Nodes, Team Discovers
Lymph nodes can provide a suitable home for a variety of cells and tissues from other organs, suggesting that a cell-based alternative to whole organ transplantation might one day be feasible, according to researchers at the University of Pittsburgh School of Medicine and the McGowan Institute for Regenerative Medicine. In a report recently published online in Nature Biotechnology, the research team showed for the first time that liver cells, thymus tissue and insulin-producing pancreatic islet cells, in an animal model, can thrive in lymph nodes despite being displaced from their natural sites.
Hepatitis virus infection, alcoholic cirrhosis and other diseases can cause so much damage that liver transplantation is the only way to save the patient, noted senior investigator Eric Lagasse, Pharm. D., Ph.D., associate professor, Department of Pathology, Pitt School of Medicine. Children with DiGeorge syndrome lack functional thymus glands to produce essential immune cells, and diabetes can be cured with a pancreas transplant.
"However, the scarcity of donor organs means many people will not survive the wait for transplantation," said Dr. Lagasse, whose lab is at the McGowan Institute. "Cell therapies are being explored, but introducing cells into tissue already ravaged by disease decreases the likelihood of successful engraftment and restoration of function."
In the study, his team tested the possibility of using lymph nodes, which are abundant throughout the body and have a rich blood supply, as a new home for cells from other organs in what is called an "ectopic" transplant.
They injected healthy liver cells from a genetically-identical donor animal into lymph nodes of mice at various locations. The result was an enlarged, liver-like node that functioned akin to the liver; in fact, a single hepatized lymph node rescued mice that were in danger of dying from a lethal metabolic liver disease. Likewise, thymus tissue transplanted into the lymph node of mice that lacked the organ generated functional immune systems, and pancreatic islet cell transplants restored normal blood sugar control in diabetic animals.
"Our goal is not necessarily to replace the entire liver, for example, but to provide sufficient cell mass to stabilize liver function and sustain the patient's life," Dr. Lagasse said. "That could buy time until a donor organ can be transplanted. Perhaps, in some cases, ectopic cell transplantation in the lymph node might allow the diseased organ to recover."
Hepatitis virus infection, alcoholic cirrhosis and other diseases can cause so much damage that liver transplantation is the only way to save the patient, noted senior investigator Eric Lagasse, Pharm. D., Ph.D., associate professor, Department of Pathology, Pitt School of Medicine. Children with DiGeorge syndrome lack functional thymus glands to produce essential immune cells, and diabetes can be cured with a pancreas transplant.
"However, the scarcity of donor organs means many people will not survive the wait for transplantation," said Dr. Lagasse, whose lab is at the McGowan Institute. "Cell therapies are being explored, but introducing cells into tissue already ravaged by disease decreases the likelihood of successful engraftment and restoration of function."
In the study, his team tested the possibility of using lymph nodes, which are abundant throughout the body and have a rich blood supply, as a new home for cells from other organs in what is called an "ectopic" transplant.
They injected healthy liver cells from a genetically-identical donor animal into lymph nodes of mice at various locations. The result was an enlarged, liver-like node that functioned akin to the liver; in fact, a single hepatized lymph node rescued mice that were in danger of dying from a lethal metabolic liver disease. Likewise, thymus tissue transplanted into the lymph node of mice that lacked the organ generated functional immune systems, and pancreatic islet cell transplants restored normal blood sugar control in diabetic animals.
"Our goal is not necessarily to replace the entire liver, for example, but to provide sufficient cell mass to stabilize liver function and sustain the patient's life," Dr. Lagasse said. "That could buy time until a donor organ can be transplanted. Perhaps, in some cases, ectopic cell transplantation in the lymph node might allow the diseased organ to recover."
Saturday, 17 November 2012
Best Ways To Manage Lymphedema: Exercise And Complete Decongestive Therapy
Nearly 40 percent of breast cancer survivors suffer from lymphedema, a chronic condition that causes body limbs to swell from fluid buildup, as a result of lymph node removal and radiation therapy. A cure for lymphedema does not exist, so individuals with the condition must find ways to manage the symptoms throughout their lifetimes. Now, a team of researchers and clinicians working with a University of Missouri lymphedema expert has found that full-body exercise and complete decongestive therapy (CDT) are the best ways for patients to minimize their symptoms and maintain their quality of life.
"There's a sense of empowerment - of autonomy - that comes from meeting the challenge of living with lymphedema," said Jane Armer, an MU nursing professor. "Some breast cancer survivors say that they've become a new person after cancer because they met a challenge, and they like the stronger person they've become. The challenge of lymphedema is similar. It's something that is pervasive in every part of life. It takes problem solving and persistence to manage the condition without letting it interfere with their goals."
Armer and her colleagues reviewed published research about lymphedema self-management in order to determine which practices were most effective in managing the condition. The researchers found that full-body exercise, such as weight lifting and stretching, was likely to be effective in minimizing lymphedema symptoms. In addition, the researchers concluded that complete decongestive therapy (CDT), a comprehensive treatment approach that incorporates skin care, exercise, manual lymphatic drainage and bandaging of swollen limbs, also helps patients effectively manage the condition.
"Previous research suggests that, the earlier the interventions, the better the outcomes," Armer said. "If patients can learn how to successfully manage the condition early on, then they can continue those processes throughout their lives, and their outcomes will be better than those of individuals who resist participating in self-care."
"There's a sense of empowerment - of autonomy - that comes from meeting the challenge of living with lymphedema," said Jane Armer, an MU nursing professor. "Some breast cancer survivors say that they've become a new person after cancer because they met a challenge, and they like the stronger person they've become. The challenge of lymphedema is similar. It's something that is pervasive in every part of life. It takes problem solving and persistence to manage the condition without letting it interfere with their goals."
Armer and her colleagues reviewed published research about lymphedema self-management in order to determine which practices were most effective in managing the condition. The researchers found that full-body exercise, such as weight lifting and stretching, was likely to be effective in minimizing lymphedema symptoms. In addition, the researchers concluded that complete decongestive therapy (CDT), a comprehensive treatment approach that incorporates skin care, exercise, manual lymphatic drainage and bandaging of swollen limbs, also helps patients effectively manage the condition.
"Previous research suggests that, the earlier the interventions, the better the outcomes," Armer said. "If patients can learn how to successfully manage the condition early on, then they can continue those processes throughout their lives, and their outcomes will be better than those of individuals who resist participating in self-care."
Thursday, 23 August 2012
New Guideline Offers Evidence-Based Testimonials On Function Of Sentinel Lymph Node Biopsy For Melanoma Staging In The U.S.A.
The American Society of Clinical Oncology (ASCO) and the Society for Surgical Oncology (SSO) have issued their first evidence-based clinical practice guideline on the use of sentinel lymph node biopsy (SLNB) to stage patients with newly diagnosed melanoma. Although SLNB has proven to be an important tool for determining prognosis and selecting treatment for many patients with melanoma, recent studies suggest that the procedure is inconsistently used. The new guideline recommendations, based on a review of all available evidence, are intended to clarify which patients should receive the procedure.
SLNB is a minimally invasive surgical technique that enables doctors to determine whether cancer has spread, a key factor in determining the appropriate surgical and drug treatments, and establishing a patient's eligibility for clinical trials. In the procedure, the "sentinel" lymph node - the node close to the tumor, to which cancer cells are most likely to spread - is removed and examined under a microscope for evidence of cancer. If cancer is found, additional surrounding lymph nodes are removed to accurately assess, or "stage," the disease and prevent further cancer spread. In most cases, however, no cancer is detected in the sentinel node and no additional lymph nodes need to be removed, allowing patients to avoid further pain, discomfort, expense, and possible side effects from a more extensive operation.
"When used for the right patients at the right time, sentinel lymph node biopsy is one of our best tools for personalizing melanoma treatment, and for sparing patients from unnecessary procedures or therapies," explained Sandra L. Wong, MD, lead author and Co-chair of the guideline panel and Assistant Professor of Surgery at the University of Michigan. "But we know this procedure is used inconsistently in the United States. We hope this guideline will provide the clarity physicians need to make the most of the procedure and further improve care for patients with melanoma."
The new clinical practice guideline was developed by a multidisciplinary panel of 14 clinical and methodological experts convened by ASCO and SSO. The panel reviewed literature published between January 1990 and August 2011, analyzing 73 studies that included more than 25,000 patients.
The guideline recommendations state the following:
SLNB is recommended for all patients with melanoma tumors of intermediate thickness (between 1 and 4 mm): Studies have shown that the technique is useful for identifying small nearby metastases in these patients, who account for about one-third of all melanoma cases. SLNB detects cancer in the sentinel node in about 18 to 26 percent of these patients, according to the guideline authors.
Evidence is insufficient to recommend routine SLNB for patients with thin melanoma tumors (less than 1 mm): Thin melanomas are the most common form of melanoma, and can usually be cured through surgical removal of the primary tumor. While SNLB is not necessary in most cases, the guideline recommendations note that it may be considered in select patients with thin melanomas who have certain high-risk factors, such as an ulcerated tumor or rapidly dividing cancer cells.
SLNB for patients with thick melanoma tumors (greater than 4 mm) may be recommended: Thick melanomas are more uncommon than the above two types, but are considered more likely to spread elsewhere in the body. While there are few studies focusing on the use of SLNB in patients with thick melanomas, use of SLN biopsy in this population may be recommended for staging purposes and to facilitate regional disease control.
Completion lymph node dissection is recommended for all patients with a positive SLNB: Complete removal of the remaining lymph nodes has been shown to prevent or limit further cancer spread in these patients. While it is not yet known whether this approach improves survival, the authors note that an ongoing study, the Multicenter Selective Lymphadenectomy Trial II, is expected to help resolve that question.
The guideline concludes that doctors should discuss SLNB as part of a comprehensive treatment planning process with their patients with melanoma. This discussion should address the risks and benefits of the procedure, and patients' individual values and preferences, so patients can make fully informed decisions.
"Our rapidly growing understanding of the biology of melanoma is driving development of more effective treatments with fewer side effects for patients," said Gary H. Lyman, MD, MPH, guideline Co-chair and Professor of Medicine and Director of Comparative Effectiveness and Outcomes Research at Duke University School of Medicine and the Duke Cancer Institute. "But to take advantage of this progress, we need to know the true extent of the disease from the start. This guideline will help ensure that sentinel lymph node biopsy is used appropriately whenever it can provide that vital information while avoiding unnecessary procedures in patients who are unlikely to benefit."
More information on the new guideline can be found at: http://www.asco.org/guidelines/snbmelanoma, and at http://www.surgonc.org--policy/practice-management/clinical-guidelines/clinical- guidelines---melanoma.aspx. A patient-oriented view of the guideline, "What to Know: ASCO/SSO Guideline on Use of Sentinel Lymph Node Biopsy for Melanoma Staging," can be found on ASCO's award-winning patient information website, http://www.cancer.net.
Lymphedema Patients Need Personalized Care
Millions of American cancer survivors experience chronic discomfort as a result of lymphedema,
a common side effect of surgery and radiation therapy in which affected
areas swell due to protein-rich fluid buildup. After reviewing
published literature on lymphedema treatments, a University of Missouri
researcher says emphasizing patients' quality of life rather than
focusing solely on reducing swelling is critical to effectively managing
the condition.
Jane Armer, professor in the MU Sinclair School of Nursing and director of nursing research at Ellis Fischel Cancer Center, said many insurance providers and health care professionals assess whether lymphedema patients need treatment based solely on how swollen their limbs are. However, several studies have shown that the volume of fluid doesn't necessarily correspond with patients' discomfort.
"Practitioners need to treat the swelling while considering patients' distress. We don't want to burden them with unnecessary or ineffective treatments," Armer said. "Health care providers should focus on managing symptoms and choose carefully among various treatments to provide individualized care plans that comfort patients, which may require modifying existing protocols."
In their literature review, Armer and her colleagues found that Complete Decongestive Therapy (CDT), a comprehensive approach for treating lymphedema involving skin care, exercise, manual lymphatic drainage and compression of the swollen limbs, may be the best form of specialized lymphedema management.
"Patients have different medical needs and come from culturally diverse backgrounds. They have different goals, support systems, pain levels and treatment tolerances. All these factors influence patients' responses to care, which affects their well-being," said Marcia Beck, a review co-author and an MU graduate who now works at Truman Medical Centers in Kansas City, Mo.
"Caring for lymphedema patients should be flexible and adjusted to maintain patients' quality of life," said Ausanee Wanchai, another co-author who received her doctorate at MU and now teaches at Boromarajonani College of Nursing in Buddhachinnaraj, Thailand.
In a separate literature review, the researchers found that Intermittent Pneumatic Compression (IPC) therapy, in which sequential inflatable devices surrounding swollen limbs are used to increase lymphatic circulation, is beneficial as an adjunct therapy for chronic lymphedema patients who have limited or no access to medical care; patients can use the compression devices in their homes.
Armer said further research is needed to demonstrate the usefulness of various lymphedema treatments, such as CDT and IPC. The literature reviews were the third and fourth in a series of 12 to be published in conjunction with the American Lymphedema Framework Project (ALFP). As director of the ALFP, Armer works alongside clinical experts and investigators to increase awareness of lymphedema and related disorders. The ALFP was founded in 2008 and is headquartered at the MU Center for Lymphedema Research, Practice and Health Policy. Its steering committee and staff currently are partnering with the International Lymphedema Framework (ILF) in producing an updated edition of the ILF Best Practice Document from 2006.
The article, "Palliative Care for Cancer-Related Lymphedema: A Systematic Review," recently was published in the Journal of Palliative Medicine. Armer's co-authors also included researchers from MU and the University of Texas. The other review, "Intermittent Pneumatic Compression Therapy: A Systematic Review," was published in the journal Lymphology earlier this year. Researchers from the NorthShore University HealthSystem, Walter Reed Military Medicine Center and University of Texas contributed to the review.
Jane Armer, professor in the MU Sinclair School of Nursing and director of nursing research at Ellis Fischel Cancer Center, said many insurance providers and health care professionals assess whether lymphedema patients need treatment based solely on how swollen their limbs are. However, several studies have shown that the volume of fluid doesn't necessarily correspond with patients' discomfort.
"Practitioners need to treat the swelling while considering patients' distress. We don't want to burden them with unnecessary or ineffective treatments," Armer said. "Health care providers should focus on managing symptoms and choose carefully among various treatments to provide individualized care plans that comfort patients, which may require modifying existing protocols."
In their literature review, Armer and her colleagues found that Complete Decongestive Therapy (CDT), a comprehensive approach for treating lymphedema involving skin care, exercise, manual lymphatic drainage and compression of the swollen limbs, may be the best form of specialized lymphedema management.
"Patients have different medical needs and come from culturally diverse backgrounds. They have different goals, support systems, pain levels and treatment tolerances. All these factors influence patients' responses to care, which affects their well-being," said Marcia Beck, a review co-author and an MU graduate who now works at Truman Medical Centers in Kansas City, Mo.
"Caring for lymphedema patients should be flexible and adjusted to maintain patients' quality of life," said Ausanee Wanchai, another co-author who received her doctorate at MU and now teaches at Boromarajonani College of Nursing in Buddhachinnaraj, Thailand.
In a separate literature review, the researchers found that Intermittent Pneumatic Compression (IPC) therapy, in which sequential inflatable devices surrounding swollen limbs are used to increase lymphatic circulation, is beneficial as an adjunct therapy for chronic lymphedema patients who have limited or no access to medical care; patients can use the compression devices in their homes.
Armer said further research is needed to demonstrate the usefulness of various lymphedema treatments, such as CDT and IPC. The literature reviews were the third and fourth in a series of 12 to be published in conjunction with the American Lymphedema Framework Project (ALFP). As director of the ALFP, Armer works alongside clinical experts and investigators to increase awareness of lymphedema and related disorders. The ALFP was founded in 2008 and is headquartered at the MU Center for Lymphedema Research, Practice and Health Policy. Its steering committee and staff currently are partnering with the International Lymphedema Framework (ILF) in producing an updated edition of the ILF Best Practice Document from 2006.
The article, "Palliative Care for Cancer-Related Lymphedema: A Systematic Review," recently was published in the Journal of Palliative Medicine. Armer's co-authors also included researchers from MU and the University of Texas. The other review, "Intermittent Pneumatic Compression Therapy: A Systematic Review," was published in the journal Lymphology earlier this year. Researchers from the NorthShore University HealthSystem, Walter Reed Military Medicine Center and University of Texas contributed to the review.
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