USE OF COMPRESSION GARMENT IN THE TREATMENT OF MALIGNANT LYMPHEDEMA IN A PATIENT WITH RECURRENT BREAST CANCER: CASE REPORT / Utilização de vestimenta compressiva no tratamento do linfedema maligno em paciente com câncer de mama recidivado: relato de caso

Introduction: Malignant lymphedema is a rapidly progressive condition, and its treatment is a major challenge. Objective: To demonstrate the benefit of using compression garments in reducing limb volume and improving the symptoms of a patient with malignant lymphedema with recurrent breast cancer. Case report: A 67-year-old woman, diagnosed with a 2.3 cm, triple negative, invasive ductal carcinoma in the left breast, submitted to quadrantectomy with axillary dissection (T2aN1bM0). The patient developed benign lymphedema after eight years of surgery, but only started complex decongestive physiotherapy three years after the diagnosis, presenting an important improvement. The following year, the patient returned with complaints of worsening lymphedema. At the examination, there was an expressive volume increase and areas of vascular alteration in the left upper limb (LUL) and in the anterior quadrant of the thorax. The exams confirmed axillary vein thrombosis due to tumor obstruction. Lymphoscintigraphy showed unsatisfactory lymphatic drainage. As a last treatment option, the use of LUL low elastic compression garment was adopted, after poor success after the use of multi-layered compression bandages. LUL volume was 6,158.1 mL prior to using the garment. After ten days of continuous use, the volume decreased to 5,174.2 mL. In the last evaluation, the volume was 4,510.8 mL, presenting a reduction of 1,647.3 mL (26.7%). The patient developed acute respiratory failure caused by pleural metastasis, and died. Conclusion: The compression garment provided benefits such as significant improvement in the feeling of heaviness in the limb due to the reduction of volume and in the ease of putting on and taking off the garment in or make the hygiene, when compared to the multilayer compression bandages. Other advantages were the reduction of costs and the promotion of well-being.

Introdução: O linfedema maligno é uma condição com rápida progressão, e seu tratamento é um grande desafio. Objetivo: Demonstrar o benefício do uso de vestimenta compressiva na redução do volume do membro e na melhora dos sintomas de uma paciente com linfedema maligno após câncer de mama recidivado. Relato de caso: Colocar paciente de 67 anos, sexo feminino, com diagnóstico de carcinoma ductal invasor em mama esquerda com 2,3 cm e triplo negativo, submetida a quadrantectomia com esvaziamento axilar (T2aN1bM0). A paciente desenvolveu linfedema benigno após oito anos de cirurgia, porém só iniciou tratamento fisioterapêutico com terapia física complexa descongestiva três anos após o diagnóstico, apresentando melhora importante. No ano seguinte, retornou ao consultório com queixa de piora do linfedema. Ao exame, apresentava aumento de volume expressivo e áreas de alteração vascular no membro superior esquerdo (MSE) e no quadrante anterior do tórax. Os exames confirmaram trombose de veia axilar por obstrução tumoral. A linfocintilografia demonstrou ausência de drenagem linfática satisfatória. Adotou-se, como última opção de tratamento, o uso da vestimenta compressiva de baixa elasticidade de MSE, após baixa resposta do enfaixamento compressivo multicamadas. O volume do MSE era de 6.158,1 mL antes do uso da vestimenta. Após dez dias contínuos de uso, o volume diminuiu para 5.174,2 mL. Na última avaliação, o volume era de 4.510,8 mL, apresentando redução de 1.647,3 mL (26,7%). A paciente evoluiu com insuficiência respiratória aguda ocasionada por metástase pleural à direita, vindo a falecer. Conclusão: A vestimenta proporcionou benefícios como melhora importante da sensação de peso no membro devido à redução de volume e facilidade em colocar e retirar a vestimenta para fazer a higiene, quando comparada ao enfaixamento compressivo multicamadas. Outras vantagens foram a redução de custos e a promoção do bem-estar.

THE VALIDITY OF AN ADJUSTABLE COMPRESSION VELCRO WRAP FOR THE TREATMENT OF PATIENTS WITH UPPER LIMB LYMPHEDEMA SECONDARY TO BREAST CANCER: A PILOT STUDY / Validação de uma vestimenta de contenção para tratamento de linfedema de membro superior secundário ao câncer de mama: estudo piloto

Objective: To analyze the efficacy of an adjustable compression Velcro wraps used to reduce limb volume as a form of treatment for upper limb lymphedema secondary to breast cancer. Methods: Women with lymphedema who had already undergone conventional treatment with compression bandaging were included. These patients were recruited through an evaluation in which the manual perimetry was applied using the truncated cone formula, and in which lymphedema were considered as a difference greater than 10% and/or 200 mL between the limbs. Patients wore their compression devices daily, taking them off only for a shower. In a period of one month of use, manual lymphatic drainage was not applied. Performing exercises was allowed 3 times a day. Patients returned after one month to have their limb volume reassessed and also to respond to a questionnaire. Results: A total of 9 patients were evaluated, and the median volume difference between the affected limb and the control during the first evaluation was 564.4 (SD=443.2) mL. At the reevaluation, the median difference was 390.6 (SD=306.8) mL. There was a significant difference when comparing the volumes at the evaluation and reevaluation (p=0.008). The degree of satisfaction was 9 (SD=1.3). Conclusion: The adjustable compression Velcro wrap was effective in the reduction of limb volume in with lymphedema. In addition, the patients reported that the device was more practical and more comfortable compared to the compression

Objetivo: A nalisar a eficácia de uma vestimenta de contenção em velcro para redução do volume do membro como forma de tratamento de linfedema de membro superior secundário ao esvaziamento axilar por câncer de mama. Métodos: Foram incluídas mulheres com linfedema que já tivessem realizado o tratamento convencional com enfaixamento compressivo. O recrutamento dessas pacientes foi através da avaliação com a perimetria manual aplicada na fórmula do cone truncado, considerando linfedema uma diferença maior que 10% e/ou 200 mL entre os membros. As pacientes deveriam utilizar diariamente a vestimenta, só retirando para tomar banho. Nesse período de um mês de uso, não deveriam fazer drenagem linfática manual, e sim apenas exercícios linfomiocinéticos três vezes ao dia. A s pacientes retornaram após um mês para a reavaliação do volume do membro e também responderam a um questionário. Resultados: Foram avaliadas 9 pacientes, sendo que a mediana de diferença de volume entre o membro afetado e o controle na primeira avaliação foi de 564,4 (DP=443,2) mL. Na reavaliação, a mediana da diferença foi de 390,6 (DP=306,8) mL. Houve diferença significativa quando comparados os volumes na avaliação e na reavaliação (p=0,008). O grau de satisfação da vestimenta foi de 9 (DP=1,3). Conclusão: A vestimenta mostrou-se eficaz como alternativa na redução do volume do membro com linfedema, e os pacientes relataram ser mais prática e proporcionar maior comodidade quanto comparada ao enfaixamento compressivo. Pacientes que moram em outras cidades ou que não têm disponibilidade para realizar tratamento diariamente podem se beneficiar do uso da vestimenta.

Evaluation of inter-rater reliability of subjective and objective criteria for diagnosis of lymphedema in upper and lower limbs / Avaliação da confiabilidade entre os critérios subjetivos e objetivos utilizados para o diagnóstico de linfedema nos membros superiores e inferiores

The diagnosis of lymphedema can be obtained objectively by measurement methods, and also by subjective methods, based on the patient's complaint. OBJECTIVE: To evaluate inter-rater reliability of objective and subjective criteria used for diagnosis of lymphedema and to propose a lymphedema cut-off for differences in volume between affected and control limbs. METHODS: We studied 84 patients who had undergone lymphadenectomy for treatment of cutaneous melanoma. Physical measures were obtained by manual perimetry (MP). The subjective criteria analyzed were clinical diagnosis of lymphedema in patients' medical records and self-report of feelings of heaviness and/or increase in volume in the affected limb. RESULTS: For upper limbs, the subjective criteria clinical observation (k 0.754, P<0.001) and heaviness and swelling (k 0.689, P<0.001) both exhibited strong agreement with MP results and there was moderate agreement between MP results and swelling (k 0.483 P<0.001), heaviness (k 0.576, P<0.001) and heaviness or swelling (k 0.412, P=0.001). For lower limbs there was moderate agreement between MP results and clinical observation (k 0.423, P=0.003) and regular agreement between MP and self-report of swelling (k 0.383, P=0.003). Cut-off values for diagnosing lymphedema were defined as a 9.7% difference between an affected upper limb and control upper limb and a 5.7% difference between lower limbs. CONCLUSION: Manual perimetry, medical criteria, and self-report of heaviness and/or swelling exhibited better agreement for upper limbs than for lower limbs for diagnosis of lymphedema...

O diagnóstico de linfedema pode ser obtido tanto de forma objetiva, por métodos de mensuração, quanto por métodos subjetivos, através da queixa do paciente. OBJETIVO: Examinar a confiabilidade entre critérios objetivos e subjetivos utilizados para o diagnóstico de linfedema e propor um ponto de corte para linfedema de membros superiores e inferiores. MÉTODOS: Foram estudados 84 pacientes submetidos à linfonodectomias para o tratamento do melanoma cutâneo. As mensurações dos membros foram feitas utilizando a perimetria manual. Os critérios subjetivos foram obtidos através do diagnóstico de linfedema nos prontuários dos pacientes (observação clínica) e de auto-relato de sensação de peso e/ou aumento de volume no membro afetado. RESULTADOS: Nos membros superiores, houve uma forte correlação entre a perimetria manual e cada um dos critérios subjetivos: observação clínica (k 0,754, P<0,001) e sensação de peso eaumento de volume (k 0,689, P<0,001); concordância moderada no aumento de volume (k 0,483, P<0,001), peso (k 0,576, P<0,001) e sensação de peso ou aumento de volume (k 0,412, P=0,001). Nos membros inferiores, houve concordância moderada entre a perimetria e observação clínica (k 0,423, P=0,003) e regular no aumento de volume (k 0,383, P=0,003). O ponto de corte para definir linfedema foi uma diferença de 9,7% entre o membro afetado e o controle, e 5,7% de diferença para membros inferiores. CONCLUSÃO: Perimetria, observação clínica e auto-relato de sensação de peso e/ou aumento de volume, apresentaram melhor concordância para membros superiores que para inferiores no diagnóstico de linfedema...

Avaliação da volumetria optoeletrônica como método diagnóstico de linfedema de membros em pacientes que realizaram linfonodectomia radical para tratamento do melanoma cutâneo / Evaluation through optoelectronic volumetry as a method of diagnosis of lymphedema limbs in patients who have lymphadenectomy radical treatment of cutaneous melanoma

INTRODUÇÃO: A volumetria optoeletrônica (VOPE) é um método inédito no Brasil, utilizado para o diagnóstico de linfedema de membros. OBJETIVOS: Avaliar um método de diagnóstico de linfedema de membros, inédito no país, em pacientes com linfonodectomias radicais como tratamento para o melanoma cutâneo, analisando a reprodutibilidade entre a VOPE e a perimetria manual (PM) e a prevalência de linfedema nestes métodos através de diferentes pontos de corte. MATERIAIS E MÉTODOS: Fizeram parte do estudo 97 indivíduos submetidos à linfonodectomia axilar (46 casos – 47,4%), inguinal (26 – 26,8%) ou ínguino-ilíaca (25 – 25,8%) no período de 1990 a 2012. Excluíram-se os pacientes com amputação de um membro ou dissecção bilateral. A mensuração de volume dos membros foi feita através da PM aplicada na fórmula do cone truncado e da VOPE (aparelho Perômetro). A diferença entre os volumes da PM e da VOPE foi verificada através do teste de Wilcoxon. O coeficiente kappa foi utilizado para verificar a concordância entre os métodos. RESULTADOS: Foram propostos pontos de corte para membros superiores, sendo uma diferença entre os membros > 7%, > 10%, > 150 ml, > 200 ml e ≥ 3 circunferências com mais de 2 cm de diferença entre o lado homolateral e contralateral e para membros inferiores > 6%, > 7%, > 300 ml, > 420 ml e ≥ 3 circunferências. As prevalências de linfedema de membro superior na VOPE variaram de 15,2% a 34,8% e na PM de 2,2% a 32,6%, já para membros inferiores, variaram de 66,7% a 80,4% na VOPE e 49,0% a 76,5% na PM. No ponto de corte > 10% para membros superiores, a prevalência foi semelhante na VOPE e na PM, porém para os demais houve divergências. A concordância entre os métodos foi satisfatória e estatisticamente significativa (linfonodectomia axilar: 0,663, p < 0,001; inguinal: 0,549, p = 0,003 e ínguino-ilíaca: 0,884, p < 0,001). CONCLUSÃO: Ambos os métodos apresentaram boa reprodutibilidade entre si, porém o Perômetro fornece uma mensuração mais precisa...

INTRODUCTION: Optoelectronic volumetry (OPVO) is a unpublished method in Brazil, used in the diagnosis of lymphedema limbs.OBJECTIVES: To evaluate a method for diagnosis of lymphedema limbs, unprecedented in the country, in patients with radical lymphadenectomies as a treatment for cutaneous melanoma, analyzing reproducibility between OPVO and manual perimetry (MP) and the prevalence of lymphedema in these methods using different cutoff points. MATERIALS AND METHODS: It was studied 97 patients who underwent axillary lymphadenectomy (46 cases - 47.4%), inguinal (26 - 26.8%) or ilio-inguinal (25 - 25.8%) in the period from 1990 to 2012. It was excluded patients with amputation of a limb or bilateral dissection. The measurement of limb volume was done by MP applied in the formula of the truncated cone and OPVO (Perometer). The difference between the volumes of the MP and OPVO was checked by Wilcoxon test. The kappa coefficient was used to assess the agreement between the methods. RESULTS: The proposed cutoff points for upper limbs are a difference between members > 7%, > 10%, > 150 ml, > 200 ml and ≥ 3 circumferences of more than 2 cm difference between the ipsilateral and contralateral side and lower limbs > 6%, > 7%, > 300 ml, > 420 mL and ≥ 3 circumferences. The prevalence of upper limb lymphedema in OPVO ranged from 15.2% to 34.8% and in MP 2.2% to 32.6%, while for lower limbs ranged from 66.7% to 80.4% in OPVO and 49.0% to 76.5% in MP. At a cutoff > 10% for upper limbs, the prevalence was similar in both OPVO and MP, but for the others cutoffs there were differences. The agreement between the methods was satisfactory and statistically significant (axillary lymphadenectomy: 0.663, p < 0.001; inguinal: 0.549, p = 0.003, and ilio-inguinal: 0.884, p < 0.001). CONCLUSION: Both methods showed good reproducibility among themselves, but Perometer provides more precise measurements, practical, fast, with instantaneous volume and compatible with the MP. The OPVO...

Analysis of physical therapy in patients who had radical lymphadenectomy for cutaneous melanoma

OBJECTIVE: Analyze if patients who had radical lymphadenectomies as a treatment for cutaneous melanoma underwent physiotherapy, observing whether or not lymphedema developed, in addition to observing what techniques were used and whether orientation as to the prevention of lymphedema was received. MATERIALS AND METHODS: We evaluated 84 patients submitted to axillary, inguinal and ilioinguinal lymphadenectomies as a treatment for cutaneous melanoma. The patients enrolled underwent an evaluation consisting of measurement of limb volume by manual perimetry and questions. RESULTS: The majority of patients with lymphedema (78.8 percent) underwent postoperative physical therapy. Somewhat troubling is the fact that only 12 individuals with lymphedema remain under treatment (36.4 percent), while the remaining 21 (63.6 percent) did not undergo physical therapy. The start of physical therapy after a 6-month postoperative period (p = 0.007) and after the onset of lymphedema (p = 0.005), performing manual lymph drainage (p = 0.008) and orientation on elastic sleeve or cuff (p < 0.001) showed statistically significant differences when compared to lymphedema and non-lymphedema patient groups. CONCLUSION: Most patients who had lymphedema underwent physiotherapy treatment. In place of a complete regimen of complex decongestive physical therapy, most patients inadequately substituted their physical therapy with isolated techniques. Most patients received orientation on how to prevent lymphedema.

Goniometric analysis of affected joints in axillary, inguinal or ilioinguinal lymphadenectomies for the treatment of cutaneous melanoma

Objectives: The objective of this study is to compare the joint range of motion (ROM) reduction between the submitted limb to lymphadenectomy and contralateral and to evaluate if ROM restriction is also connected with lymphedema. Materials and Methods: Evaluated were 84 patients submitted to axillary lymphadenectomy (n=40), inguinal (21) or ilioinguinal (23) for the treatment of cutaneous melanoma, operated between 1990 and 2008. Individuals excluded were those with amputation of a limb or bilateral dissection that would make perimetry and goniometry comparison impossible. The invited patients were submitted to goniometric evaluation of the shoulder or hip and measurement of the upper or lower limbs through manual perimetry. Results: The difference of 4.2 degrees between the averages of ROM flexion (p=0.005) of the shoulder of the affected side in relation to the control, and 5.2 degrees in abduction (p=0.002) were sufficient to be statistically significant, with the exception of 3 degrees of external rotation (p=0.135). The differences between the means of hip ROM were also significant, varying 8.5 degrees in flexion (p <0.001) and 2.2 degrees in abduction (p=0.011). The ROM of the shoulder or hip of the affected side did not present differences between the 33 patients with lymphedema in relation to the 51 patients without lymphedema: shoulder with flexion (p=0.148), abduction (p=0.577) and external rotation (p=0.866); hip with flexion (p = 0.665) and abduction (p=0.795). Conclusion: In spite of individuals with lymphadenectomy show restriction of joint ROM in flexion and abduction of the shoulder and hip in the late postoperative period, there was no association between joint ROM, of the shoulder on both the hip and the presence of lymphedema.