No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Improving Lymphatic Drainage with Herbal Preparations: A Potentially Novel Approach to Management of Lymphedema
Abstract
Lymphedema is a potentially debilitating condition with particularly high incidence among breast cancer patients following surgery. Horsechestnut (Aesculus hippocastanum) and butcher's broom (Ruscus aculeatus) have been shown by herbalists to improve peripheral vascular circulation and lymphatic drainage. Nuclear medicine lymphoscintigraphy offers a tool to quantitate the effects of their combination in Horsechestnut Complex on lymphatic drainage rates. Methods: A prospective clinical trial in 15 normal volunteers was undertaken using a repeat measures design. Bilateral upper limb lymphoscintigraphy was performed on each volunteer at baseline and following a 3 month course of Horsechestnut Complex . Lymphatic drainage rates were quantitatively evaluated. Results: A significant increase was noted in the percentage of activity that migrated away from the injection site with respect to baseline versus follow up series. The baseline mean of 6.63% varied significantly from the follow up mean of 8.19% (p = 0.002) over a 2 hour sampling window. The matched pairs t test indicated a statistically significant difference (p = 0.017) with a mean increase in percentage migration of 1.56% after herbal treatment (95% CI 0.30% - 2.82%). Conclusion: The herbal formulation evaluated has the potential to accelerate lymphatic drainage in the normal population. A randomised controlled trial to evaluate the potential clinical benefits in breast cancer patients with post treatment lymphedema may be warranted.
... Through its activation of a-adrenergic receptors, it produces a vasoconstrictive effect. It has diuretic, anti-inflammatory, and venotonic properties and may also help heal the capillaries to prevent macromolecule seepage [25,26]. ...
... HCSE, a saponin, has been shown to inhibit the activity of proteolytic enzymes, elastase and hyaluronidase, in vitro [35]. It is thought that this enzyme activity initiates the cascade of events that cause capillary leakage and inflammation in persons with CVI [25,35,36]. A Cochrane review that included evidence from 17 RCTs showed that HCSE reduces edema and leg pain related to CVI when used with compression or as a monotherapy [35]. ...
... In one unique trial with healthy volunteers, participants were studied with a baseline upper limb lymphoscintigraphy. For 3 months, they took an HCSE, butcher's broom, and Ginkgo biloba combination (Horsechestnut Complex) preparation twice a day after meals and then had a follow-up lymphoscintigraphy scan [25]. Wheat et al [25] report a significant increase in the percentage of lymphatic drainage activity that migrated away from the lymphoscintigraphy injection site when baseline and follow-up series were compared. ...
Objectives
1) To provide a critical analysis of the current published research regarding the use, risks and benefits of botanicals in the treatment of lymphedema; and 2) to provide health professionals current knowledge of safe, appropriate use of botanicals for lymphedema
Type
This systematic search and review (SSR) addresses the use of botanicals in the treatment of lymphedema in order to develop a best evidence synthesis of the research.
Literature Survey
Articles were identified from 11 major medical indices published from 2004-2012 using search terms for lymphedema and management. Eighty-five articles met the inclusion criteria of evidence-based lymphedema therapies for the category “complementary and alternative methods for lymphedema therapy.”
Methodology
Two clinical lymphedema experts reviewed the studies according to level of evidence guidelines established by the Oncology Nursing Society, Putting Evidence into Practice (PEP) and subdivided the methods into sub-categories that included Botanical, Pharmaceutical, Physical Agent Modalities (PAM) and Modalities of Contemporary Value (MCV). The pharmaceutical articles were excluded (5), falling outside the inclusion criteria. Twenty-two articles were used in a separate review of PAM and MCV for lymphedema. Botanicals generated substantial research (11) and warranted its own independent review.
Synthesis
The levels of evidence are weak, as research conclusions were limited by size, dose, and study design. There are limited Randomized Control Trials (RCT) and reliability is not always evident, particularly in the context of large systematic reviews where evidence was bundled.
Conclusions
There is insufficient evidence supporting the use of botanicals for the treatment of lymphedema. Some evidence suggests benefits for the treatment of chronic venous insufficiency. Development of specific and sensitive measurement methods may change how botanicals are studied and establish a body of evidence for their use.
... Since Aβ is transported along this route, its impairment may contribute to accumulation of amyloid [482], tau and lead to neurodegeneration [483]. Plants with therapeutic bioactivity in stimulating lymphatic drainage, such as Aesculus hippocastanum [484], could thus be explored for a possible similar role in improving glymphatic function. ...
Alzheimer’s disease (AD) is progressive and ultimately fatal, with current drugs failing to reverse and cure it. This study aimed to find plant species which may provide therapeutic bioactivities targeted to causal agents proposed to be driving AD. A novel toolkit methodology was employed, whereby clinical symptoms were translated into categories recognized in ethnomedicine. These categories were applied to find plant species with therapeutic effects, mined from ethnomedical surveys. Survey locations were mapped to assess how this data is at risk. Bioactivities were found of therapeutic relevance to 15 hypothesised causal bases for AD. 107 species with an ethnological report of memory improvement demonstrated therapeutic activity for all these 15 causal bases. The majority of the surveys were found to reside within biodiversity hotspots (centres of high biodiversity under threat), with loss of traditional knowledge the most common threat. Our findings suggest that the documented plants provide a large resource of AD therapeutic potential. In demonstrating bioactivities targeted to these causal bases, such plants may have the capacity to reduce or reverse AD, with promise as drug leads to target multiple AD hallmarks. However, there is a need to preserve ethnomedical knowledge, and the habitats on which this knowledge depends.
Graphical Abstract
To review the evidence for the effectiveness of complementary and alternative medicine (CAM) on cancer-related lymphedema.
CINAHL, PsycINFO, and PubMed (1990-2012).
To date, there is insufficient evidence to draw conclusions about the benefits of CAM use for cancer patients with lymphedema. Although some CAM types may offer positive effects for the management of lymphedema, negative adverse effects have also been observed.
Oncology nurses and therapists should be aware of and ready to educate cancer patients about the potential effects of CAM. A conversation about the potential risks and benefits of CAM use should be provided.
Extract of Ruscus aculeatus is used in treatment of venous insufficiency. In the present study, we used the hamster cheek pouch preparation and investigated in vivo the effects of an alpha 1 and alpha 2 adrenoceptor antagonists, a calcium blocker, Ruscus extract, and their combination on increased microvascular permeability induced by histamine. Experiments were performed on male hamsters; 30 min after completion of the cheek pouch preparation, fluorescein-labeled dextran (molecular weight 150,000) was given intravenously (i.v.). Histamine, applied topically, increased the number of fluorescent vascular leakage sites from postcapillary venules, evidence of an increase in macromolecular permeability, which was quantified by ultraviolet light microscopy as the number of leaky sites in the prepared area. Prazosin (alpha 1-adrenoceptor antagonist), diltiazem (calcium blocker), and Ruscus extract applied topically dose-dependently inhibited the macromolecular permeability-increasing effect of histamine. Rauwolscine (alpha 2-adrenoceptor antagonist), also applied topically, had no effect on histamine-induced permeability increase. Inhibition of the histamine-induced permeability increase evoked by Ruscus extract could be blocked by prazosin and by diltiazem but not by rauwolscine. These results indicate that any variation in the transmembrane flux of calcium impairs formation of microvascular leaky sites by histamine. Our results show that Ruscus extract has a protective effect against the leakage of FITC-dextran in hamster cheek pouch after administration of histamine that is modulated by calcium and selectively by alpha 1-adrenoceptors.
The Ruscus extract and the flavonoid hesperidine methylchalcone (HMC) are used in treatment of venous insufficiency. In the present study, we used the hamster cheek pouch preparation and investigated the effects of these substances on increased microvascular permeability induced by bradykinin, histamine, and leukotriene B4 (LTB4) applied topically. Experiments were performed on male hamsters; 30 min after completion of the cheek pouch preparation, fluorescein-labeled dextran [molecular weight (mol wt) 150,000] was given intravenously (i.v.). Bradykinin, histamine, and LTB4 increased the number of fluorescent vascular leakage sites from postcapillary venules, evidence for an increase in macromolecular permeability, which was quantified in ultraviolet (UV)-light microscope as the number of leaky sites in the prepared area. Ruscus extract and HMC, given i.v., significantly inhibited the macromolecular permeability-increasing effect of bradykinin, LTB4, and histamine. Ruscus extract, applied topically, dose dependently inhibited the macromolecular permeability-increasing effect of histamine. Our results show that Ruscus extract and HMC have a protective effect against leakage of FITC-dextran in the cheek pouch after administration of various permeability-increasing substances, which further supports data previously reported on patients with venous insufficiency.
Fifty seven patients with secondary lymphedema of the upper limb after previous treatment for breast cancer were treated for 3 months with an extract of Ruscus + Hesperidin Methyl Chalcone (CYCLO 3 FORT) or placebo according to a double-blind protocol in the context of a controlled clinical trial. All patients also underwent manual lymphatic drainage twice a week for at least one month. With CYCLO 3 FORT, the reduction in volume of arm edema, the main assessment criteria, was 12.9% after 3 months of treatment as compared with a placebo (p=0.009). Decreased edema tended to be more marked in the forearm compared with the upper arm where excess fat deposition seemed to dominate over excess fluid accumulation. CYCLO 3 FORT was well tolerated with minimal adverse reaction.
Breast conservation has been shown to be a safe and effective alternative to mastectomy in early-stage breast cancer. The present study reviews the long-term outcome and toxicity after treatment of early breast cancer by conservative surgery and radiation.
Between November 1979 and December 1989, 438 patients with Union Internationale Contre le Cancer (UICC) stage I or II breast cancer were treated with conservative surgery and radiation therapy (CS+RT) at Westmead Hospital. Surgery to the breast varied from a local excision to a quadrantectomy, depending on the preference of the referring surgeon. The axilla was surgically dissected in 299 patients (68%). All patients received postoperative breast irradiation. The whole breast was irradiated to 46-54 Gy (median dose, 50 Gy) using 6 Mev photons for 5-6.5 weeks. Boosts were given at the primary tumour site in 336 patients (78%), by electron therapy (88 patients), iridium-192 (247 patients) or photons (one patient). A total of 44 patients (10%) received adjuvant chemotherapy.
The median follow-up period for surviving patients was 84 months (range: 56-172 months). The 5-year actuarial rate of local recurrence was 6% (312 patients at risk), and the 10-year rate was 10% (52 patients at risk). Very young patients (aged 34 years at diagnosis) had a 5-year actuarial rate of local recurrence of 13% compared to 5% for older patients (P = 0.04). Neither the total dose to the primary site nor the boost technique influenced local recurrence. The 5-year freedom from distant relapse was 83%. The side effects included rib fractures (2%), symptomatic pneumonitis (3%), fatty necrosis or fibrosis requiring surgery (4%), and moderate-severe oedema of the arm (7%).
The long-term data show that CS+RT for UICC stage I or II breast cancer results in low rates of local recurrence which are influenced by age at diagnosis, but not by radiation dose or boost technique. These results confirm those of other international series that CS+RT is a safe alternative to mastectomy for most women with operable breast cancer.
To analyse breast cancer mortality trends in Australia and to see if mammographic screening has yet led to a reduction in mortality.
Retrospective analysis of trends in mortality rates from breast cancer in Australian women between 1921 and 1994, and in potentially explanatory variables such as fertility, body size, age at menarche, and screening.
Changes in breast cancer mortality in Australian women could not be explained by chance variation alone. Mortality rose steadily (average annual increase, 1.0%) to 1940-1944, fell to the 1960s and early 1970s, and rose (average annual increase, 0.3%) to the late 1980s. Between 1985-1989 and 1990-1994, breast cancer mortality fell by 3.2% in women 50-69 years of age (the target age group for mammographic screening) and by 4.2% in women 25-49 years of age. There was almost on change (-0.2%) in breast cancer mortality in older women in this period. The proportion of women screened in all age groups increased substantially between 1988 and 1994; nearly 65% of women in the target age group had had at least one mammogram by 1994. Decreases in fertility were followed by increases in mortality, and vice versa.
Trends in breast cancer mortality have probably been influenced by changing fertility, nutrition and body-size increases among Australian women. Improvements in stage at diagnosis and treatment have probably moderated the upwards pressure on mortality caused by an increasing incidence. Recent falls in mortality could be expected to continue as more women participate in the mammographic screening program. This trend should be more clearly evident in the second half of the 1990s.
To assess the evidence for or against horse-chestnut seed extract (HCSE) as a symptomatic treatment of chronic venous insufficiency (CVI).
Computerized literature searches were performed in MEDLINE, EMBASE, BIOSIS, CISCOM, and the Cochrane Library (all from their respective institution to December 1996). The search terms were "horse chestnut," "Aesculus hippocastanum," "escin," and "Rosskastanie" (German for "horse chestnut"). There were no restrictions on the language of publication.
Double-blind, randomized controlled trials of oral HCSE for patients with CVI were included. Identifiers were removed from all publications before assessment.
Data were extracted in a standardized, predefined manner. Trial outcomes and the methodological quality of each trial were independently assessed by the 2 reviewers.
The superiority of HCSE is suggested by all placebo-controlled studies. The use of HCSE is associated with a decrease of the lower-leg volume and a reduction in leg circumference at the calf and ankle. Symptoms such as leg pain, pruritus, and a feeling of fatigue and tenseness are reduced. Five comparative trials against the reference medication indicate that HCSE and O-(beta-hydroxyethyl)-rutosides are equally effective. One trial suggests a therapeutic equivalence of HCSE and compression therapy. Adverse effects are usually mild and infrequent.
These data imply that HCSE is superior to placebo and as effective as reference medications in alleviating the objective signs and subjective symptoms of CVI. Thus, HCSE represents a treatment option for CVI that is worth considering.
Lymphoedema can be a devastating complication of surgical treatment for breast cancer. There is a lack of research on its prevalence in Australia which has hindered the development of measures to combat the condition. The aims of this study were to establish the prevalence and investigate the aetiology of upper limb lymphoedema in women treated for breast cancer in the years 1994-1996 in southern Tasmania.
A standard volumetric water displacement technique was used to measure the arms of 201 women. A subjective assessment of swelling was also made by each patient. Factors analysed for statistical association with lymphoedema were: patient characteristics, type of treatment and tumour, and lymph node pathology.
The overall objective prevalence rate, regardless of treatment type, was 11%; whereas, the subjective rate was 23.4%. The objective prevalence for procedures involving axillary surgery was 14.2%. Significant statistical associations were found between arm size and body mass index at time of assessment (r = 0.15, P = 0.04); type of surgery (Chi-squared test = 11.06, P = 0.05); surgery to axilla (U = 2515.5, P = 0.002); tumour size (r = 0.17, P = 0.03); and tumour grade (Chi-squared test = 6.5 1, P = 0.04). No significant relationship was found between lymphoedema and axillary irradiation, number of lymph nodes removed, age or handedness of the patient.
Women receiving axillary dissection as part of their breast cancer treatment carry a significant risk of developing lymphoedema, regardless of the extent of surgery. The causative role of axillary irradiation was not supported. Future research should concentrate on less invasive alternatives to axillary dissection, such as sentinal lymph node biopsy.
Population-based women (n=1049) with breast cancer diagnosed mainly between 1996 and 1998, when aged 20-59 years, were mailed a questionnaire seeking information about self-reported shoulder stiffness and swelling, numbness and pain/ache in the arm following treatment (excluding 6 months from diagnosis). Of the 809 who completed the survey, approximately seven in eight experienced at least one symptom, one in six reported all four symptoms, and one in three considered that their arm morbidity interfered substantially with activities of daily living. Arm swelling occurred at some time in 39% of women, was present in 20% 1 year, and in 29% 4 years, after diagnosis. The prevalence of arm swelling was higher in women with axillary node dissection (OR=2.4; 95% Cl 1.0-5.6), and was increased in a women with a higher body mass index (P=0.02) and less education (P=0.01), but was not related to age, number of nodes excised or self-reports of radiation or type of surgery.