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What is lymphedema and how to prevent it?

Lymphedema is an accumulation of fluid that causes swelling in the arm. It can start right after surgery or radiation therapy, or come on months or years later. Most often, it appears slowly. It occurs in women who have had their axillary lymph nodes removed during surgery, or who have received radiation therapy in the area of the lymph nodes. Approximately one in five women with breast cancer will have lymphedema.

The prevention of lymphedema should be started as early as possible, that is, from the diagnosis of cancer and the definition of the oncological treatment to be carried out. The physiotherapist can carry out prevention through guidance on the care of the ipsilateral upper limb (UL) (maintain hydration, use repellents against insect bites, avoid trauma, burns, blood pressure measurement and puncture in this limb) and best way to perform your usual activities (domestic, work and leisure).

Healthy lifestyle habits must be encouraged (food, physical activity, body weight control) and, when necessary, referral to other health professionals (nutritionist, occupational therapist, psychologist, physician, social worker, nurse, among others) ).

Aiming to reduce capillary ultrafiltration and the consequent increase in interstitial fluid, patients should be advised to avoid using superficial or deep heat in the UL ipsilateral to the surgery, as well as not performing fast, repetitive movements with overload of this limb. The application of physical therapy resources that generate superficial and/or deep heat is contraindicated in the UL ipsilateral to surgery.

MMSS exercises should be started early, slowly, without resistance and with few repetitions. Muscle contraction resulting from therapeutic exercises promotes lymphatic angiomotricity, improves tone.

Main care:

• Keep your skin hydrated and clean. Avoid and treat mycoses on the nails and arms.

• Avoid skin trauma (cuts, scratches, insect bites, burns, cuticle removal and waxing).

• Wear protective gloves when doing household activities (cooking, gardening, washing dishes and contact with chemicals).

• Do not use hot tubs and saunas.

• During air travel, avoid immobility of upper limbs.

• Avoid squeezing the arm on the operated side (elastic blouses, watches, tight rings and bracelets, blood collection, taking blood pressure).

• Watch for signs of infection in the arm (redness, swelling, local heat).

• Avoid sudden, repeated and long-lasting movements.

• Avoid carrying heavy objects on the surgery side.












                                          Upper limb lymphedema and elastic cuff


What are predictive and prognostic factors for breast cancer?

The factor is considered predictive when it provides useful information in the selection of patients susceptible to a specific therapy. The prototype predictive marker are hormone receptors, which mediate the response to adjuvant hormone therapy, and HER 2 in target therapy.

Prognostic factor is any characteristic of the patient or tumor that can be used to predict the natural history of the neoplasm, response to treatment, or overall survival time. The most considered prognostic factors are tumor size, degree of differentiation, menopausal status, axillary lymph node involvement, hormone receptors, HER2 and Ki 67 proliferation index.

What is the adjuvant treatment after initial breast cancer surgery?

The proposal of adjuvant therapy for breast cancer is based on the clinical staging and molecular profile of the tumor, associated in some cases with one of the available genetic signatures, thus establishing the best treatment. The indication of cytotoxic therapy and molecular target drugs in early breast carcinoma can also be supported by validated mathematical models such as Predict Breast Cancer

Systemic adjuvant programming is directed according to the molecular profile of breast tumors, according to the classification below, represented in the table below.







“Luminal A” tumors have a low response to chemotherapy treatment, due to low proliferation, and are therefore not candidates for adjuvant chemotherapy treatment in the initial disease, in these cases hormonal manipulation is the adjuvant treatment of choice. Options are tamoxifen or aromatase inhibitors (for postmenopausal women only) for 5 to 10 years.

  “Luminal B” tumors present an intermediate proliferation, being responsive to both cytotoxic and hormonal therapy. The differentiation of luminal tumors, based on the immunohistochemical determination (IHC) of the Ki-67 proliferative index, is not presented in a safe way, due to tumor pleomorphism. The use of genetic signatures, such as Oncotype Dx®1, Mammaprint®, Endopredict®, among others, have become standard for choosing adjuvant therapy; low risk, only hormone therapy; high risk, chemotherapy, followed by hormonal manipulation.

In tumors at high risk of recurrence, the indication for adjuvant chemotherapy is defined. The choice of the best regimen is based on the molecular profile and potential risk of each patient. Another point of great relevance is related to the period for starting adjuvant chemotherapy, several studies suggest that the delay in starting leads to a reduction in the relapse-free interval and overall survival. It is recommended that adjuvant chemotherapy treatment should start within four weeks after surgery.

For patients with ER/PR and HER2 negative disease (triple negative breast cancer), adjuvant chemotherapy is given if the tumor size is ≥0.5 cm. As these patients are not candidates for endocrine therapy or treatment with HER2-targeted agents, chemotherapy is their only option for adjuvant treatment, after or before radiotherapy. Patients with triple-negative breast cancer <0.5 cm in size are not candidates for chemotherapy. Future perspectives point towards the development of molecular target drugs in triple negative tumors, which is still a challenge in breast oncology. In tumors with mutations in the BRCA gene, inhibitors of the enzyme poly ADP ribose polymerase (PARP) and of the antiprogrammed death receptor-1 (PD-L1) appear as hope in this molecular subtype, according to studies carried out in metastatic disease

Patients with HER2-positive breast cancer with a tumor size > 1 cm should receive a combination of chemotherapy and HER2-targeted therapy.  Currently, double blockade with trastuzumab and pertuzumab is recommended. The treatment of small HER2-positive breast cancers (≤1 cm) is controversial. In patients with tumors between 0.6 - 1 cm (T1b) with negative lymph nodes, the use of adjuvant chemotherapy can be considered, although data are still conflicting, but recent studies show an advantage, both in local and distant recurrence

After chemotherapy, patients with ER-positive disease should also receive adjuvant endocrine therapy.

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Sorocaba Medical Center


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Americas Medical City

Barra da Tijuca

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