Clinical experience in treating 78 cases of upper limb edema after breast cancer operation by WenYang HuoXue Washing Prescription

Hong Chen,Xing-Yuan Wang,Bao-Ya Zhao,Zhong-Hua Zhang,Shuang-Wen Liu,Yun-Lan Jiao*Department of oncology of Dongfang Hospital，Beijing University of Chinese Medicine,Beijing,China.

Background

Upper limb edema after breast cancer surgery is a common clinical complication of breast cancer patients,namely breast cancer related lymphedema(BCRL).Studies have shown that the incidence of BCRL is between 6% and 62.5%[1-3].BCRL often causes patients to suffer from swelling,abnormal appearance,upper limb movement disorder and fatigue,and it is difficult to eliminate.Although some progress has been made in the treatment of BCRL in recent years,there is still lack of simple and effective methods for clinical treatment[4].In oncology department of Dongfang Hospital,Beijing University of Chinese Medicine,we collected 78 patients were treated with WenYang HuoXue Washing prescription(WYHX),from July 2014 to August 2015 to evaluate the therapeutic effect.The report is as follows.

clinical information

Case source

Seventy-eight female BCRL patients admitted to the Dongfang Hospital,Beijing University ofChinese Medicine,from July 2014 toAugust 2015 were selected.

Diagnostic criteria

Diagnostic Criteria for BCRL: According to industry-recognized standards[5],four points(transverse wrist,10 cm on the wrist,10 cm on the elbow and 10 cm on the elbow)of the affected limb after the operation of breast cancer were taken.The average circumference was 2cm above the corresponding healthy side,which could be defined as upper limb edema.The same measurement point was measured twice,and all measurement data were recorded in Centimeter in a unified manner.

BCRL staging criteria:According to the American Physical Therapy Association's BCRL staging criteria[6],there are 4 phases.Each stage of patient has a"heavy"or"full"feeling of the upper limbs.The difference between each stage is that:at stage 0,the hand/upper limb was repeatedly swollen,with an increase of 0~1 cm compared with the preoperative circumference,and there was no dent in finger pressure.In stage I,the hand/upper limb was swollen most of the time,and the circumference was increased by 1~2 cm.Slight indentation edema.In phase II,hand/upper limb swelling continued throughout the day,and the swelling began to affect function and aesthetic appearance,with an increase of 2~4 cm in diameter and non-indentation edema of finger pressure.In stage III,pigmentation on the basis of stage II increased by more than 4cm.

case inclusion criteria

① Age is older than 18 years of age.② Patient is consistent with the diagnosis of upper extremity edema after breast cancer surgery.③ Patients with Edema stage I or II.④ Local syndrome is cold syndrome:aversion to cold,consciously cold;skin temperature is low,skin color not red,etc.

Case exclusion criteria

① Patients with tumor metastasis and lymph node metastasis of the affected limb.②There are thrombotic diseases,phlebitis,lymphangitis and other vascular and lymphangitic diseases in the affected limb of a person.③The affected limb has macules,papules,erythema,herpes,exfoliative dermatitis or ulcerative dermatitis. ④Pregnant and lactating women.

Method

Treatment

The 78 patients were treated with traditional Chinese medicine(TCM)sock method of WYHX.The specific procedures are as follows:1.Dilute 1 bag of medicine with hot water to 500 mL,pour into the insulated bowl,let stand for 3 min.2.The thermometer to measure the drug temperature,temperature maintenance at about 40°C.3.After exposing the affected limb,the gauze should be wrapped around the affected area,which should be larger than the upper and lower limit of the swelling area by 2 cm.4.Take the warming bowl close to the affected limb,pour the warm water on the gauze evenly and slowly,and drench with the gauze.The patient feels that the skin temperature is appropriate.5.Spray the solution every 5 to 10 minutes to keep it moist and warm.The application will be carried out once a day for 40 to 60 minutes each time,during 9 to 11 o'clock every day.

The WYHX istheexperience prescription of Professor Hu Kaiwen of the Oncology Department of Dongfang hospital.The prescription includes GanJiang(Zingiber oj-jicinale Rosc.)300g,RouGui(Cinnamomum cassia Presl)300,ShuJiao(Zanthoxylum bungeanum Maxim)300g and DangGui(Angelica sinensis)300g.These are the doses for 10 days.Add 8 times of water to the above 4 ingredients,and cook them twice,45min each time,filter them,combine with the decoction,place them overnight,take the supernatant and concentrate them to 1000 mL,then pack them(100 mL/bag).

Wet compress care

The doctor told the patient about the effect of TCM wet compress,the brief process and the possible skin reaction,to relieve the bad mood of the patient and to check whether the local skin is intact,whether there is rupture,swelling,etc.,and the underlying pad is once and for all.Select the dressing specification according to the wet compress.Pour the liquid with the right temperature into the container,soak it in the solution solution,wring it with tweezers(suitable humidity),shake it and fold it and apply it to the affected area.Also keep warm to prevent cold.

During treatment:The nurses asked patients about their subjective feelings to improve their comfort.The dressing should be replaced at intervals of 5-10 min to maintain its humidity and temperature,and be wet for 40-60 min each time.In the process of wet application,the skin feels warm,hot and some slight tingling,which is a normal phenomenon under the action of drugs.The local skin condition and patient's reaction should be closely observed.If symptoms such as pale,red spots,blisters,itchy pain or rupture occur,the treatment should be stopped immediately and treated accordingly.

After treatment:Nursing staff help patients dry the local liquid,place the patients,arrange the bedsheets and answer the patients'questions timely and effectively,so as to improve the treatment compliance.

Therapeutic observation

Observation indicators According to the previous study of the research group[7],the course of treatment was 14d.The disability ofarm-shoulder-hand (DASH)was recorded before treatment and after 14 days of treatment,and the DASH changes were compared.The total clinical effective rate(effective and effective percentage of total population)and adverse reactions were finally evaluated.

Criterion of therapeutical effect[7]Markedly effective:DASH value drops by 10 points or more(excluding 10 points).Effective:DASH value drops by 5~10 points.Invalid:DASH value decreases by less than 5 points or DASH value increases.

The DASH score sheet consists of two parts,A and B[8].Part A is used to evaluate the upper limb functional activities of the patient,such as wearing sweaters and vigorously cutting vegetables.PartB investigates symptoms of upper limb discomfort such as shoulder numbness,stiffness and movement disturbance.The DASH value is calculated by adding all the numbers of the two parts A and B,and then calculating according to the following formula:DASH value=[A and B 2 partial value sum-30(lowest value)]/1.20.

Results

General information

The mean age of 78 female patients was 60.12+9.64 years.All the surgical methods were modified radical mastectomy.Postoperative mean survival time was(39.51+7.38)months.Mean course of edema(11.48+5.46)months.There were 51 cases of edema stage I and 27 cases of stage II.

Comparison of therapeutic effects

After 14 days of treatment,the DASH function score of 23 patients improved by more than 10 points,the DASH value of 41 cases decreased between 5 and 10 points,the decrease of DASH value of 6 cases was less than 5 points,and the DASH value of 8 cases was higher than before.Combined with the above,the total effective rate was 64.According to the staging of edema,there were 51 patients in stage I and 27 patients in stage II.The total effective number(Markedly effective+effective)of the two groups was compared by chi-square test.There was no significant difference(P>0.05)(Table 1).

Adverse reactions

No adverse reactions occurred in all cases.

Table 1 Comparison of clinical effects between the two groups according to edema

Discussion

BCRL is caused by treatment damage of breast cancer(such as axillary lymph node dissection,radiotherapy),postoperative complications(incision infection and scar hyperplasia),impedimentto upperlimb lymphatic drainage,large amount of protein-containing lymph fluid retention tissue gap.At the same time,the tissue osmotic pressure increased,so that the amount of fluid entering the interstitial space of the capillaries increased,and finally tissue edema appeared[9].

Upper extremity edema after breast cancer surgery belongs to the category of"edema"in TCM.Traditional Chinese medicine believes that its pathogenesis is that the body is not adequately qi,and it is treated by surgery,the veins are damaged,the blood is not running smoothly,the blood and water stasis,which cause edema.It is necessary to adopt the principle of curing evil,and the major method of treating it is warming Yang and activating blood circulation.In the previous study,the research group observed the syndrome characteristics of 129 postoperative patients with breast cancer[10],and found that77% ofpatientswereyang deficiency syndrome.Their local manifestations of the skin color were not red,skin cool like warm Yang deficiency cold syndrome.The research group member Gao Lei[7]used the method of“warming yang and benefiting qi,inducing diuresis for removing edema”as the basic of self-made prescription named “Wentong Xiaozhong External Application”,He uses parallel randomized,double blind,placebo controlled,multicenter clinical study design scheme to treat BCRL patients.In 96 patients,84 patients completed the study.The course of treatment was 14 days.The circumference of the arm and the DASH value were the main evaluation indexes.The effective rate of the test group was 51.3%,and the effective rate of the control group was 68.9%.There was no significant difference(P=0.12).The reason for the negative result of the study was related to the use of mirabilite with coldness in the of Wentong Xiaoyan External Application.On the other hand,the main evaluation criteria were mainly Western medicine,but the use of Chinese medicine is not lawful.Based on this,the research group treated patients with breast cancer with local syndrome differentiation of upper limb edema with cold syndrome based on the WYHX summarized by professor Hu Kaiwen.The clinical efficacy was evaluated purely from the perspective of TCM,and the primary objective was to improve patients'subjective symptoms.The results of this study showed that the WYHX can effectively improve breast cancer postoperative upper extremity edema,han zheng limb symptoms.The total effective rate is 82.1%,but there is no significant difference between stage I and stage II according to edema stage(P>0.05).There was no adverse events occurred during the study period.The main medicine is dried ginger and cinnamon.This recipe takes GanJinag and RouGui as the main medicine,they are hot,belong to the spleen meridians,have the function of warming the meridians of the spleen and radiating the cold to pass the pulse,have the wonderful effect to the swelling pain caused by various cold.The above two herbs can be combined with ShuJiao can into the spleen dehumidification,curing wind,cold and wet bi,edema diarrhea.GanJiang and ShuJiao have the functions of dissipating the cold evil and stopping the pain swelling.In the prescription,DangGui is the most important drug to promote blood circulation and blood stasis,as well as to assist cold relief of Ganjiang and RouGui.All kinds of medicines are used together to make up the effect of warming the blood and promoting blood circulation.The four flavors of the prescriptions belong to the spleen,and all the dampness and swelling belong to the spleen.Therefore,we chose to use the washing prescription from 9 am to 11 am of the spleen meridian.

To sum up,the treatment of BCRL by TCM alone can improve the arm swelling,pain,numbness and other discomfort symptoms of patients to some extent,but it still cannot be completely relieved.For the treatment of BCRL,the early prevention of the occurrence of BCRL by optimized surgical methods and surgical techniques is thekey.Thecombination ofTCM and western physiotherapy is the best choice for obtaining better curative effect at present.At the same time,on the basis of summarizing the above experiences,a higher quality randomized,blind multicenter clinical controlled study can be further carried out in the future,in order to form a standardized and scientific TCM diagnosis and treatment plan for upper extremity edema after breast cancer operation.

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