Post-Mastectomy Lymphedema

J Surg Res. 2010 Apr 18. [Epub ahead of print]

Treatment of Post-Mastectomy Lymphedema with Laser Therapy: Double Blind Placebo Control Randomized Study.

Ahmed Omar MT, El Morsy AM, Abd-El-Gayed Ebid A.

Faculty of Physical Therapy, Cairo, Egypt. Member of International Panel of Advisory Board for Indian Journal of Physiotherapy and Occupational Therapy.

Abstract

BACKGROUND: In post-mastectomy patients, lymphedema has the potential to become a permanent progressive condition and become extremely resistant to treatment. Thus, it can results in function impairment and decrease quality of life. The aim of this study was to evaluate the effect of low level laser therapy (LLLT) on limb volume, shoulder mobility, and hand grip strength.

MATERIAL AND METHODS: Fifty women with breast cancer-related lymphedema were enrolled in a double-blind, placebo controlled trial. Patients were randomly assigned to active laser (n = 25) and placebo (n = 25) groups and received irradiation with Ga-As laser device that had wavelength of 904 nm, power of 5 mW, and spot size of 0.2 cm(2) over the axillary and arm areas, three times a week for 12 wk. The total energy applied at each point was 300 mjoules over seven points, giving a dosage of 1.5 joules/cm(2) in the active group. The placebo group received placebo therapy in which the laser had been disabled without affecting its apparent function. Limb circumference, shoulder mobility, and grip strength were measured before treatment and at 4, 8, and 12 wk.

RESULTS: The two groups had similar parameters at baseline. The reduction of limb volume tended to decline in both groups. The trend being more significantly pronounced in active LLLT group than placebo at 8 and 12 wk, respectively (P < 0.05). Goniometric data for shoulder mobility and hand grip strength were statistically significance for LLLT group than for placebo.

CONCLUSION: Laser treatment was found to be effective in reducing the limb volume, increase shoulder mobility, and hand grip strength in approximately 93% of patients with postmastectomy lymphedema

Photomed Laser Surg. 2010 Feb;28(1):115-23.

The effect of laser irradiation on proliferation of human breast carcinoma, melanoma, and immortalized mammary epithelial cells.

Powell K, Low P, McDonnell PA, Laakso EL, Ralph SJ.

School of Medical Science, Griffith University, Gold Coast, Queensland, Australia.

Abstract

OBJECTIVE: This study compared the effects of different doses (J/cm(2)) of laser phototherapy at wavelengths of either 780, 830, or 904 nm on human breast carcinoma, melanoma, and immortalized human mammary epithelial cell lines in vitro. In addition, we examined whether laser irradiation would malignantly transform the murine fibroblast NIH3T3 cell line.

BACKGROUND: Laser phototherapy is used in the clinical treatment of breast cancer-related lymphoedema, despite limited safety information. This study contributes to systematically developing guidelines for the safe use of laser in breast cancer-related lymphoedema.

METHODS: Human breast adenocarcinoma (MCF-7), human breast ductal carcinoma with melanomic genotypic traits (MDA-MB-435S), and immortalized human mammary epithelial (SVCT and Bre80hTERT) cell lines were irradiated with a single exposure of laser. MCF-7 cells were further irradiated with two and three exposures of each laser wavelength. Cell proliferation was assessed 24 h after irradiation.

RESULTS: Although certain doses of laser increased MCF-7 cell proliferation, multiple exposures had either no effect or showed negative dose response relationships. No sign of malignant transformation of cells by laser phototherapy was detected under the conditions applied here.

CONCLUSION: Before a definitive conclusion can be made regarding the safety of laser for breast cancer-related lymphoedema, further in vivo research is required.

Support Care Cancer. 2010 May 6. [Epub ahead of print]

The short-term effects of low-level laser therapy in the management of breast-cancer-related lymphedema.

Dirican A, Andacoglu O, Johnson R, McGuire K, Mager L, Soran A.

Department of Surgery, Division of Surgical Oncology, Magee-Womens Hospital University of Pittsburgh Medical Center, Pittsburgh, PA, USA.

Abstract

BACKGROUND: Breast-cancer-related lymphedema (BCRL) is a chronic disease, and currently there is no definitive treatment for it. There are some therapeutic interventions targeted to decrease the limb swelling and the associated problems. Low-level laser therapy (LLLT) has been used in the treatment of post-mastectomy lymphedema since 2007 in the US. The aim of this study is to review our short-term experience with LLLT in the treatment of BCRL.

METHOD: Seventeen BCRL patients referred to our lymphedema program between 2007 and 2009 were enrolled in this study. All patients had experienced at least one conventional treatment modality such as complex physical therapy, manual lymphatic drainage, and/or pneumatic pump therapy. LLLT was added to patients’ ongoing therapeutic regimen. All patients completed the full course of LLLT consisting of two cycles. The difference between sums of the circumferences of both affected and unaffected arms (DeltaC), pain score, scar mobility, and range of motion were measured before and after first and second cycles of LLLT sequentially.

RESULTS: All patients were female with a median age of 51.8 (44-64) years. DeltaC decreased 54% (15-85%) and 73% (33-100%), after the first and second cycles of LLLT, respectively. Fourteen out of seventeen experienced decreased pain with motion by an average of 40% (0-85%) and 62.7% (0-100%) after the first and second cycle of LLLT, respectively. Three patients had no improvement in pain after LLLT. Scar mobility increased in 13 (76.4%) and shoulder range of motion improved in 14 (82.3%) patients after LLLT. One patient developed cellulitis during LLLT.

CONCLUSION: Patients with BCRL received additional benefits from LLLT when used in conjunction with standard lymphedema treatment. These benefits include reduction in limb circumference, pain, increase in range of motion and scar mobility. Additionally, two cycles of LLLT were found to be superior to one in this study.

Photomed Laser Surg. 2009 Oct;27(5):763-9.

Managing postmastectomy lymphedema with low-level laser therapy.

Lau RW, Cheing GL.

Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong SAR, China.

OBJECTIVE: We aimed to investigate the effects of low-level laser therapy (LLLT) in managing postmastectomy lymphedema.

BACKGROUND DATA: Postmastectomy lymphedema (PML) is a common complication of breast cancer treatment that causes various symptoms, functional impairment, or even psychosocial morbidity. A prospective, single-blinded, controlled clinical trial was conducted to examine the effectiveness of LLLT on managing PML.

METHODS: Twenty-one women suffering from unilateral PML were randomly allocated to receive either 12 sessions of LLLT in 4 wk (the laser group) or no laser irradiation (the control group). Volumetry and tonometry were used to monitor arm volume and tissue resistance; the Disabilities of Arm, Shoulder, and Hand (DASH) questionnaire was used for measuring subjective symptoms. Outcome measures were assessed before and after the treatment period and at the 4 wk follow-up.

RESULTS: Reduction in arm volume and increase in tissue softening was found in the laser group only. At the follow-up session, significant between-group differences (all p < 0.05) were found in arm volume and tissue resistance at the anterior torso and forearm region. The laser group had a 16% reduction in the arm volume at the end of the treatment period, that dropped to 28% in the follow-up. Moreover, the laser group demonstrated a cumulative increase from 15% to 33% in the tonometry readings over the forearm and anterior torso. The DASH score of the laser group showed progressive improvement over time.

CONCLUSION: LLLT was effective in the management of PML, and the effects were maintained to the 4 wk follow-up.

Clin Rehabil. 2009 Feb;23(2):117-24

Efficacy of pneumatic compression and low-level laser therapy in the treatment of postmastectomy lymphoedema: a randomized controlled trial.

Kozanoglu E, Basaran S, Paydas S, Sarpel T.

Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Cukurova University, Adana, Turkey.

Objective: To compare the long-term efficacy of pneumatic compression and low-level laser therapies in the management of postmastectomy lymphoedema.

Design: Randomized controlled trial.Setting: Department of Physical Medicine and Rehabilitation of Cukurova University, Turkey.Subjects: Forty-seven patients with postmastectomy lymphoedema were enrolled in the study.Interventions: Patients were randomly allocated to pneumatic compression (group I, n=24) and low-level laser (group II, n=23) groups. Group I received 2 hours of compression therapy and group II received 20 minutes of laser therapy for four weeks. All patients were advised to perform daily limb exercises.

Main measures: Demographic features, difference between sum of the circumferences of affected and unaffected limbs (triangle upC), pain with visual analogue scale and grip strength were recorded.

Results: Mean age of the patients was 48.3 (10.4) years. triangle upC decreased significantly at one, three and six months within both groups, and the decrease was still significant at month 12 only in group II (P = 0.004). Improvement of group II was greater than that of group I post treatment (P = 0.04) and at month 12 after 12 months (P = 0.02). Pain was significantly reduced in group I only at posttreatment evaluation, whereas in group II it was significant post treatment and at follow-up visits. No significant difference was detected in pain scores between the two groups. Grip strength was improved in both groups, but the differences between groups were not significant.

Conclusions: Patients in both groups improved after the interventions. Group II had better long-term results than group I. Low-level laser might be a useful modality in the treatment of postmastectomy lymphoedema.

Tanzan Health Res Bull. 2007 May;9(2):121-5.

The effect of mastectomy and radiotherapy for breast carcinoma on soft tissues of the shoulder and its joint mobility among Egyptian patients.

Saied GM, Kamel RM, Dessouki NR.

Department of General Surgery, Faculty of Medicine, Cairo University, Egypt.

Abstract

Patients with post mastectomy soft tissue shoulder disorders usually benefit from various lines of physiotherapy treatment. However, the controversy about their efficacy persists. The aim of this work was to study and assess the efficacy of each, and to identify the best intervention. One hundred female patients with ipsilateral post mastectomy shoulder problems were enrolled in the study, from September 2003 until December 2004. They were followed up for 32 weeks. Mastectomy, both radical and conservative and axillary lymph node clearance, was the standard surgery applied for operable breast carcinoma in this series. Clinical examination was followed by testing for the shoulder complaint by measuring maximal protrusion at the inferior scapular angle, scapular stabilization and the lift-off tests. Approved physiotherapy modalities were then applied, viz: no treatment (randomly chosen 12 patients), passive and active motion therapy (14 patients), oral diclofenac sodium (19 patients), local triamcinilone injection (40 patients) and manually applied low intensity laser therapy (15 patients). Assessment was by determining overall success rate for each intervention modality. Intervention outcome was assessed at 8, 16, and 32 weeks as shown by physical examination using the healthy shoulder as a reference, and by measuring restricted mobility during passive lateral rotation and glenohumeral abduction. “Success rate” was determined separately for each group at the end of the intervention period. The applied surgery was followed by radiotherapy in 96%, chemotherapy in 24% and both in 11%. The presenting post mastectomy symptoms at the shoulder were pain (100%), shoulder weakness (88%), winging of the scapula (11%) and inability to perform everyday shoulder movements (23%). Evaluation was by overall improvement score. The results were: 14.3% for untreated patients, 43.3% for those treated by motion therapy, 42% for diclofenac therapy, 80.7% for local triamcinolone, and lastly 68% for low intensity laser therapy. All treatment regimens for shoulder disabilities in those patients gave little long-term advantage, local steroid injections were the most effective. Low level laser therapy may augment its effect. It is concluded that all treatment regimens provide little long-term advantage; however, trimcinilone local injections may be the most useful in terms of pain relief and improvement in shoulder movement.

Ann Oncol. 2007 Apr;18(4):639-46. Epub 2006 Oct 3

A systematic review of common conservative therapies for arm lymphoedema secondary to breast cancer treatment.

Moseley AL, Carati CJ, Piller NB.

School of Nursing & Midwifery, University of South Australia, Adelaide, Australia. amanda.moseley@yahoo.com.au

Secondary arm lymphoedema is a chronic and distressing condition which affects a significant number of women who undergo breast cancer treatment. A number of health professional and patient instigated conservative therapies have been developed to help with this condition, but their comparative benefits are not clearly known. This systematic review undertook a broad investigation of commonly instigated conservative therapies for secondary arm lymphoedema including; complex physical therapy, manual lymphatic drainage, pneumatic pumps, oral pharmaceuticals, low level laser therapy, compression bandaging and garments, limb exercises and limb elevation. It was found that the more intensive and health professional based therapies, such as complex physical therapy, manual lymphatic drainage, pneumatic pump and laser therapy generally yielded the greater volume reductions, whilst self instigated therapies such as compression garment wear, exercises and limb elevation yielded smaller reductions. All conservative therapies produced improvements in subjective arm symptoms and quality of life issues, where these were measured. Despite the identified benefits, there is still the need for large scale, high level clinical trials in this area.

Lasers Med Sci. 2006 Jul;21(2):90-4. Epub 2006 May 4.

Low-level laser therapy in management of postmastectomy lymphedema.

Kaviani A, Fateh M, Yousefi Nooraie R, Alinagi-zadeh MR, Ataie-Fashtami L.

Tehran University of Medical Sciences and Iranian Center for Medical Laser Research, Tehran, Iran. akaviani@sina.tims.ac.ir

The aim of this paper was to study the effects of low-level laser therapy (LLLT) in the treatment of postmastectomy lymphedema. Eleven women with unilateral postmastectomy lymphedema were enrolled in a double-blind controlled trial. Patients were randomly assigned to laser and sham groups and received laser or placebo irradiation (Ga-As laser device with a wavelength of 890 nm and fluence of 1.5 J/cm2) over the arm and axillary areas. Changes in patients’ limb circumference, pain score, range of motion, heaviness of the affected limb, and desire to continue the treatment were measured before the treatment and at follow-up sessions (weeks 3, 9, 12, 18, and 22) and were compared to pretreatment values. Results showed that of the 11 enrolled patients, eight completed the treatment sessions. Reduction in limb circumference was detected in both groups, although it was more pronounced in the laser group up to the end of 22nd week. Desire to continue treatment at each session and baseline score in the laser group was greater than in the sham group in all sessions. Pain reduction in the laser group was more than in the sham group except for the weeks 3 and 9. No substantial differences were seen in other two parameters between the two treatment groups. In conclusion, despite our encouraging results, further studies of the effects of LLLT in management of postmastectomy lymphedema should be undertaken to determine the optimal physiological and physical parameters to obtain the most effective clinical response.

Cancer. 2003 Sep 15;98(6):1114-22.

Treatment of postmastectomy lymphedema with low-level laser therapy: a double blind, placebo-controlled trial.

Carati CJ, Anderson SN, Gannon BJ, Piller NB.

Department of Anatomy, School of Medicine, Flinders University, Adelaide, South Australia, Australia. colin.carati@flinders.edu.au

Erratum in:

  • Cancer. 2003 Dec 15;98(12):2742.

Abstract

BACKGROUND: The current study describes the results of a double blind, placebo-controlled, randomized, single crossover trial of the treatment of patients with postmastectomy lymphedema (PML) with low-level laser therapy (LLLT).

METHODS: Participants received placebo or one cycle or two cycles of LLLT to the axillary region of their affected arm. They were monitored for reductions in affected limb volume, upper body extracellular tissue fluid distribution, dermal tonometry, and range of limb movement.

RESULTS: There was no significant improvement reported immediately after any of the treatments. However, the mean affected limb volume was found to be significantly reduced at 1 month or 3 months of follow-up after 2 cycles of active laser treatment. Approximately 31% of subjects had a clinically significant reduction in the volume of their PML-affected arm (> 200 mLs) approximately 2-3 months after 2 cycles of treatment. There was no significant effect of placebo treatment, or one cycle of laser treatment, on affected limb volume. The extracellular fluid index of the affected and unaffected arms and torso were reported to be significantly reduced at 3 months after 2 cycles of laser therapy, and there was significant softening of the tissues in the affected upper arm. Treatment did not appear to improve range of movement of the affected arm.

CONCLUSIONS: Two cycles of laser treatment were found to be effective in reducing the volume of the affected arm, extracellular fluid, and tissue hardness in approximately 33% of patients with postmastectomy lymphedema at 3 months after treatment.

Used by the kind permission of the Czech Society for the Use of Laser in Medicine, www.laserpartner.org

Lymphoedema and Laser Therapy

Ann Thelander, A.U.A. (Dipl. Physio), M.A.P.A. Mitcham Rehab Clinic, 9 Princes Road, Kingswood, S.A 5062, Australia

Published jointly in Laser Partner and Laser World (www.laser.nu)

Abstract

In a very simplified way, the author deals with causes of lymphoedema and with its main features. She describes a method of treatment of this pathology, underlining in particular the role of irradiation with a therapeutic laser. Given procedures and promissing results are worth further thorough clinical evaluation.

Introduction

Lymphoedema develops in people born with inadequate lymphatic systems which have difficulty transporting the lymphatic load. This can be from hypoplasia (not enough vessels or nodes), and what they have does not work very well. This is primary lymphoedema and tends to be genetically inherited. A secondary form of lymphoedema is more common in which the lymphatic system has been damaged by surgery or radiotherapy or other trauma. The trauma of removal of varicose veins or other veins for heart surgery can lead to overload of the previously normal lymphatic system. Spider bites from several spiders can lead to lymphoedema.

Lymphoedema is a progressive condition with four main characteristics (1):

  1. excessive protein in the tissues
  2. excessive fluid in the tissues (both intra and extracellular fluid)
  3. excessive deposition of fibrous tissue
  4. chronic inflammatory reactions.

The excess fluid and fibre are immediately under the skin and well within the reach of the laser beam. New lymph vessels cannot grow through scar tissue or fibrosed tissues. Following laser therapy there is a softening of the tissues and reduction in the fluid. New lymph vessels can grow (2). The limbs do not reduce in size until there is softening.

In 1993 a pilot study was undertaken to determine the effect of laser therapy in large post mastectomy arms of 4 or more years duration. (3). This trial found that the arms responded well to laser therapy – there was reduction in the amount of oedema and the volume of extracellular fluid as measured by bioimpedence, the tissues became softer as measured by tonometry and the patients perceived an improvement in symptoms of bursting pains, tightness, heaviness, cramps, pins and needles, mobility and limb circumference. The arms lost a mean 19.7% collectively during the 16 treatments and we then continued to measure them and a further loss of 7% occurred over the following 6 months. During this 6 months there was no treatment of any kind and they did not wear support sleeves.

With improved measuring techniques (perometry, tonometry, and bioimpedence and sometimes lymphoscintigraphy) we can detect areas of fibrosis and blockages and can target these areas with the laser, to get better results. In the trial all the patients had identical treatment.

Method

The current assessment and treatment used at Mitcham Rehab Clinic and The Lymphoedema Assessment Clinic at Flinders Surgical Oncology Clinic at Flinders Medical Centre is a full assessment of external measurements, volume and circumference at 200 positions using the Perometer. The resistancce of the tissues to compression is measured by the tonometer. Bioimpedence shows the fat, fluid (intra and extracellular) and fibre in the tissues. Measurements are taken on both arms or both legs. Subjective information on heaviness, cramps, pins and needles and range of movement are all recorded.

Laser therapy then targets the areas of blockage or fibrosis starting over the chest wall and axilla and moving distally in the arm or, for the leg, lymphoedema abdominal scars and the inguinal region are treated first and then progress distally. Fifty minutes of scanning laser precedes an hour of Complex Physical Therapy – massage.

The laser used is a He Ne unit with an output of 9 mW at 632.8 nm and peak power of 4 x 27 mW GaAs at 904 nm scanning laser which covers an area of 20 x 30 cm. The energy density was 2-4 J per cm2.

Interesting Observations

Most of the patients with lymphoedema feel the effect of the laser at the time of treatment – what they feel is pulsing in the limb distal to where the laser is shining. Several people with whole body primary lymphoedema can feel pulsing in their face or arms while the laser is on their leg, proving the generallized stimulating effect on the whole lymphatic system in an active lymphatic system.

Lymphoedema patients tend to get skin infections like cellulitis which often requires hospitalization, but following laser therapy and massage their tissues become healthier (less fibre and fluid) and their rate of infection drops dramatically.

A few people – about 7 out of over 700 treated with laser for lymphoedema have suffered a reaction – overdose. They all describe themselves are sensitive and cannot take drugs, even non prescription drugs. Several had drastic reactions to Radiotherapy. The reaction these people have had is feeling very tired and sleepy for 24 hours after the laser. On subsequent treatments the laser power level has been reduced considerably and they get a normal treatment effect with no sleepiness. Could this effect be from stimulating light sensitive areas that regulate the body’s clock as described in Newscientist?

An exciting reaction we found in a 43 year old woman who developed lymphoedema of the face neck and left arm following surgery and 2 courses of radiotherapy for cancer of the thyroid 9 years before. Her vocal cords were badly affected by the radiotherapy and for 9 years she could not talk but only whisper. She could not use the phone and working at a whisper was tiring and difficult. After the first treatment of laser to her neck she could talk!! After 10 treatments she could start speech therapy and sing a little. She now speaks normally and her lymphoedema has reduced considerably.

References

  1. Piller N B (1994): The Management and Treatment of Lymphoedemas. Journal of the National Womens¹ Health Group, Australian Physiotherapy Association, Volume 13, page 17 – 25
  2. Lievens P (1987):The Influence of Laser Treatment on the Lymphatic System and Wound Healing. Medical Laser Report 5/6 Torino, Italy, p 29-31.
  3. Piller N B, Thelander A (1995): Treating Chronic Post Mastectomy Lymphoedema with LLLT: a Cost Effective Strategy to Reduce Severity and Improve the Quality of Survival. Laser Therapy Vol 7 No 4 p163-168
Lymphology. 1998 Jun;31(2):74-86.

Treatment of chronic postmastectomy lymphedema with low level laser therapy: a 2.5 year follow-up.

Piller NB, Thelander A.

Department of Public Health, School of Medicine, Flinders Medical Centre, Bedford Park, South Australia. binbp@flinders.edu.au

Ten women with unilateral arm lymphedema after axillary clearance (radical mastectomy) and radiotherapy for breast cancer received 16 treatment sessions with Low Level Laser Therapy (LLLT) over 10 weeks and seven patients were followed for 36 months. The effect of LLLT was monitored by arm circumference, plethysmography, tonometry, bioimpedance and a questionnaire dealing with subjective symptoms. After treatment, edema volume (both extracellular and intracellular) was decreased, the tissue (except for the upper arm) progressively softened or approached a normal texture, and the patients reported improvement in aches/pains, tightness, heaviness, cramps, pins/needles, and mobility of the arm. Skin integrity was also improved and the index for risk of infection decreased. Follow-up assessment at 1, 3, 6, and 30-36 months showed varying trends although at 30-36 months most subjective parameters and bioimpedance derived data on ECF and ICF tended to return toward pre-treatment levels. Arm circumference continued to show overall improvement, however, with a volume reduction of the affected arm reaching 29%. Tonometry also showed maintenance of near normal values for the involved forearm and anterior and posterior chest; however, the upper arm showed progressive induration. The data suggest that laser treatment, at least initially, improved most objective and subjective parameters of arm lymphedema.