Breast Cancer Presenting as Unilateral Arm Edema
Identifieur interne : 001C05 ( Pmc/Corpus ); précédent : 001C04; suivant : 001C06Breast Cancer Presenting as Unilateral Arm Edema
Auteurs : Shaheen Zakaria ; Ruth Johnson ; Barbara A. Pockaj ; Amy C. DegnimSource :
- Journal of General Internal Medicine [ 0884-8734 ] ; 2007.
Abstract
Symptomatic arm lymphedema as the presenting symptom of invasive breast carcinoma is a rare occurrence.
We report a case of invasive breast cancer presenting with unilateral arm swelling. The patient was initially thought to have venous thrombosis. A thorough physical examination and a mammogram revealed the presence of breast cancer and associated subclinical axillary lymphadenopathy.
Failure to recognize this presentation can lead to misdiagnosis or a significant delay in diagnosis and treatment.
Url:
DOI: 10.1007/s11606-006-0077-0
PubMed: 17443377
PubMed Central: 1852908
Links to Exploration step
PMC:1852908Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Breast Cancer Presenting as Unilateral Arm Edema</title><author><name sortKey="Zakaria, Shaheen" sort="Zakaria, Shaheen" uniqKey="Zakaria S" first="Shaheen" last="Zakaria">Shaheen Zakaria</name><affiliation><nlm:aff id="Aff1">Department of Surgery, Mayo Clinic, 200 First St. SW, Rochester, Minnesota 55905 USA</nlm:aff></affiliation></author><author><name sortKey="Johnson, Ruth" sort="Johnson, Ruth" uniqKey="Johnson R" first="Ruth" last="Johnson">Ruth Johnson</name><affiliation><nlm:aff id="Aff2">Departments of Internal Medicine, Mayo Clinic, Rochester, Minnesota USA</nlm:aff></affiliation></author><author><name sortKey="Pockaj, Barbara A" sort="Pockaj, Barbara A" uniqKey="Pockaj B" first="Barbara A." last="Pockaj">Barbara A. Pockaj</name><affiliation><nlm:aff id="Aff3">Department of Surgery, Mayo Clinic, Scottsdale, Arizona USA</nlm:aff></affiliation></author><author><name sortKey="Degnim, Amy C" sort="Degnim, Amy C" uniqKey="Degnim A" first="Amy C." last="Degnim">Amy C. Degnim</name><affiliation><nlm:aff id="Aff1">Department of Surgery, Mayo Clinic, 200 First St. SW, Rochester, Minnesota 55905 USA</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">17443377</idno><idno type="pmc">1852908</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1852908</idno><idno type="RBID">PMC:1852908</idno><idno type="doi">10.1007/s11606-006-0077-0</idno><date when="2007">2007</date><idno type="wicri:Area/Pmc/Corpus">001C05</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">001C05</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Breast Cancer Presenting as Unilateral Arm Edema</title><author><name sortKey="Zakaria, Shaheen" sort="Zakaria, Shaheen" uniqKey="Zakaria S" first="Shaheen" last="Zakaria">Shaheen Zakaria</name><affiliation><nlm:aff id="Aff1">Department of Surgery, Mayo Clinic, 200 First St. SW, Rochester, Minnesota 55905 USA</nlm:aff></affiliation></author><author><name sortKey="Johnson, Ruth" sort="Johnson, Ruth" uniqKey="Johnson R" first="Ruth" last="Johnson">Ruth Johnson</name><affiliation><nlm:aff id="Aff2">Departments of Internal Medicine, Mayo Clinic, Rochester, Minnesota USA</nlm:aff></affiliation></author><author><name sortKey="Pockaj, Barbara A" sort="Pockaj, Barbara A" uniqKey="Pockaj B" first="Barbara A." last="Pockaj">Barbara A. Pockaj</name><affiliation><nlm:aff id="Aff3">Department of Surgery, Mayo Clinic, Scottsdale, Arizona USA</nlm:aff></affiliation></author><author><name sortKey="Degnim, Amy C" sort="Degnim, Amy C" uniqKey="Degnim A" first="Amy C." last="Degnim">Amy C. Degnim</name><affiliation><nlm:aff id="Aff1">Department of Surgery, Mayo Clinic, 200 First St. SW, Rochester, Minnesota 55905 USA</nlm:aff></affiliation></author></analytic><series><title level="j">Journal of General Internal Medicine</title><idno type="ISSN">0884-8734</idno><idno type="eISSN">1525-1497</idno><imprint><date when="2007">2007</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Context</title><p>Symptomatic arm lymphedema as the presenting symptom of invasive breast carcinoma is a rare occurrence.</p></sec><sec><title>Design</title><p>We report a case of invasive breast cancer presenting with unilateral arm swelling. The patient was initially thought to have venous thrombosis. A thorough physical examination and a mammogram revealed the presence of breast cancer and associated subclinical axillary lymphadenopathy.</p></sec><sec><title>Conclusion</title><p>Failure to recognize this presentation can lead to misdiagnosis or a significant delay in diagnosis and treatment.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct></listBibl></div1></back></TEI><pmc article-type="research-article"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">J Gen Intern Med</journal-id><journal-title>Journal of General Internal Medicine</journal-title><issn pub-type="ppub">0884-8734</issn><issn pub-type="epub">1525-1497</issn><publisher><publisher-name>Springer-Verlag</publisher-name><publisher-loc>New York</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">17443377</article-id><article-id pub-id-type="pmc">1852908</article-id><article-id pub-id-type="publisher-id">77</article-id><article-id pub-id-type="doi">10.1007/s11606-006-0077-0</article-id><article-categories><subj-group subj-group-type="heading"><subject>Case Reports/Clinical Vignettes</subject></subj-group></article-categories><title-group><article-title>Breast Cancer Presenting as Unilateral Arm Edema</article-title></title-group><contrib-group><contrib contrib-type="author"><name name-style="western"><surname>Zakaria</surname><given-names>Shaheen</given-names></name><degrees>MD</degrees><address><phone>+1-507-2844499</phone><fax>+1-507-2845196</fax></address><xref ref-type="aff" rid="Aff1">1</xref></contrib><contrib contrib-type="author"><name name-style="western"><surname>Johnson</surname><given-names>Ruth</given-names></name><degrees>MD</degrees><xref ref-type="aff" rid="Aff2">2</xref></contrib><contrib contrib-type="author"><name name-style="western"><surname>Pockaj</surname><given-names>Barbara A.</given-names></name><degrees>MD</degrees><xref ref-type="aff" rid="Aff3">3</xref></contrib><contrib contrib-type="author" corresp="yes"><name name-style="western"><surname>Degnim</surname><given-names>Amy C.</given-names></name><degrees>MD</degrees><address><email>Degnim.Amy@mayo.edu</email></address><xref ref-type="aff" rid="Aff1">1</xref></contrib><aff id="Aff1"><label>1</label>Department of Surgery, Mayo Clinic, 200 First St. SW, Rochester, Minnesota 55905 USA</aff><aff id="Aff2"><label>2</label>Departments of Internal Medicine, Mayo Clinic, Rochester, Minnesota USA</aff><aff id="Aff3"><label>3</label>Department of Surgery, Mayo Clinic, Scottsdale, Arizona USA</aff></contrib-group><pub-date pub-type="epub"><day>17</day><month>1</month><year>2007</year></pub-date><pub-date pub-type="ppub"><month>5</month><year>2007</year></pub-date><volume>22</volume><issue>5</issue><fpage>675</fpage><lpage>676</lpage><permissions><copyright-statement>© Society of General Internal Medicine 2007</copyright-statement></permissions><abstract><sec><title>Context</title><p>Symptomatic arm lymphedema as the presenting symptom of invasive breast carcinoma is a rare occurrence.</p></sec><sec><title>Design</title><p>We report a case of invasive breast cancer presenting with unilateral arm swelling. The patient was initially thought to have venous thrombosis. A thorough physical examination and a mammogram revealed the presence of breast cancer and associated subclinical axillary lymphadenopathy.</p></sec><sec><title>Conclusion</title><p>Failure to recognize this presentation can lead to misdiagnosis or a significant delay in diagnosis and treatment.</p></sec></abstract><kwd-group><title>Key words</title><kwd>breast cancer</kwd><kwd>lymphedema</kwd><kwd>diagnosis</kwd></kwd-group><custom-meta-wrap><custom-meta><meta-name>issue-copyright-statement</meta-name><meta-value>© Society of General Internal Medicine 2007</meta-value></custom-meta></custom-meta-wrap></article-meta></front><body><sec id="Sec1"><title>Introduction</title><p>Breast cancer represents a significant source of morbidity and mortality in developed countries. Although the most common presentations of breast cancer are a palpable mass or an abnormal screening mammogram, there are less common presentations that must be considered.<xref ref-type="bibr" rid="CR1">1</xref>–<xref ref-type="bibr" rid="CR3">3</xref> We present a case report where the initial manifestation of breast malignancy was ipsilateral arm edema.</p></sec><sec id="Sec2"><title>Case</title><p>A 73-year-old white woman was referred to the Vascular Center and Lymphedema Clinic by her local primary care provider for evaluation of chronic left arm swelling. She reported an insect sting 10 months ago, with immediate swelling in the left hand, followed by swelling of the left arm from the wrist to the shoulder. Over the ensuing months, her hand swelling improved, but the left arm swelling persisted. Elastic wrapping of the arm yielded no significant improvement. Initial work-up by her primary care provider within the first month of presentation consisted of a left arm ultrasound that was negative for venous thrombosis. Three months later a chest computed tomography (CT) scan was obtained, which was unremarkable. This CT scan was reviewed at our institution upon her referral. A calcified granuloma was noted in the left lung, but there were no abnormal findings of the left breast or axilla.</p><p>She denied past history of vascular thrombosis, pulmonary embolus, significant trauma, or surgery on the left breast, chest or arm. The only previous breast history was a benign biopsy of her right breast several years ago. Her most recent screening mammogram (done 2 months before the onset of arm swelling) was negative. She had never been on hormone replacement therapy and had no known familial predisposition for cancer. Her current medications included a beta blocker, an angiotensin converting enzyme inhibitor, a lipid lowering agent, and aspirin.</p><p>On examination at our institution, she was overweight, with a BMI of 28.5 kg/m<sup>2</sup>. Her left upper extremity had significant skin thickening and changes consistent with lymphedema extending from the left clavicular region to the dorsal aspect of the hand. The digits were uninvolved. Normal peripheral pulses were present in all 4 extremities. There was no cervical, supraclavicular, or infraclavicular adenopathy. Although mild general fullness of the left axilla was appreciated, no discrete lymphadenopathy was discernable. Breast examination revealed large, pendulous, and symmetrical breasts without skin dimpling or nipple retraction. Vague nodularity was noted in the far left upper outer quadrant, but a discrete lump was not palpable.</p><p>Venous ultrasound examination of the left upper extremity was repeated and showed no thrombosis. Lymphoscintigraphy of both upper extremities demonstrated prompt ascent of activity into right axillary nodes, but no lymphatic drainage on the left with a pronounced dermal pattern consistent with lymphedema. Repeat mammogram at this time showed 2 irregular nodules in the tail of the left breast, and ultrasound showed suspicious left axillary lymphadenopathy. Fine-needle aspiration cytology of the 2 breast nodules and axillary lymph nodes revealed adenocarcinoma. The patient underwent wide local excision of the left breast cancer and axillary lymph node dissection. Pathology revealed multifocal grade 2 invasive ductal carcinoma (1.6 and 1.2 cm), and all 10 axillary lymph nodes were involved with metastatic adenocarcinoma with some extracapsular extension. A positron emission tomography (PET) scan and bone scan showed no distant metastatic disease. The patient received adjuvant chemotherapy and radiotherapy to the breast and nodal fields.</p></sec><sec id="Sec3"><title>Discussion</title><p>Most breast cancers present as a palpable mass or an abnormality on screening mammography. The percentage of cancers detected by screening mammography varies, affected by the degree of participation in screening programs and the age group of the population being screened.<xref ref-type="bibr" rid="CR4">4</xref> Only a minority of patients present with other signs or symptoms. Initial presentation of breast cancer as clinically palpable axillary adenopathy with negative breast imaging (generally referred to as “occult breast cancer”) is a rare occurrence (0.3–0.8%).<xref ref-type="bibr" rid="CR3">3</xref>,<xref ref-type="bibr" rid="CR5">5</xref> Other unusual presenting symptoms of breast cancer include acute venous thrombosis,<xref ref-type="bibr" rid="CR6">6</xref> Mondor’s disease,<xref ref-type="bibr" rid="CR7">7</xref> pituitary insufficiency,<xref ref-type="bibr" rid="CR8">8</xref> vaginal bleeding secondary to metastasis to uterine cervix,<xref ref-type="bibr" rid="CR9">9</xref> and paraneoplastic syndrome.<xref ref-type="bibr" rid="CR10">10</xref></p><p>Our patient is unusual because of her sole presenting symptom of ipsilateral arm edema, most likely caused by breast cancer obstructing axillary lymphatics. The differential diagnosis for a patient presenting with a swollen extremity includes muscle strain, fracture, hematoma, cellulitis, vasculitis, superficial thrombophlebitis, chronic venous insufficiency, deep venous thrombosis, and lymphedema secondary to lymphatic obstruction. The approach to initial evaluation of unilateral arm edema should include detailed history and complete physical examination (including breast examination), plain x-ray of the involved extremity, and Doppler ultrasound and/or venogram to rule out venous thrombosis. The diagnosis of lymphedema should always be entertained in a patient with unilateral arm edema and no venous obstruction. Lymphedema is a swelling in the soft tissues of the limb secondary to impaired lymphatic drainage. This most commonly occurs because of damaged lymphatics from trauma, surgery or radiation, but can also occur because of extensive tumor growth obstructing lymphatic flow. Unfortunately, breast malignancy leading to obstructed lymphatic flow was not considered in the initial differential diagnosis as a possible etiology for the symptoms in this patient. Awareness of this rare manifestation of a common problem like breast cancer is essential to timely diagnosis and treatment.</p></sec><sec id="Sec4"><title>Conclusion</title><p>Breast cancer is a common disease that can have uncommon initial presentations, which divert attention from the underlying malignancy. In our patient, arm lymphedema resulted from extensive nodal involvement from breast cancer. This case report highlights the importance of having a high clinical suspicion for breast cancer in a patient who presents with unilateral arm lymphedema. Failure to recognize this presentation can lead to misdiagnosis or a significant delay in diagnosis and treatment.</p></sec></body><back><ack><p><bold>Potential Financial Conflicts of Interest</bold> None disclosed.</p></ack><ref-list id="Bib1"><title>References</title><ref id="CR1"><label>1.</label><citation citation-type="journal"><person-group person-group-type="author"><name><surname>Osteen</surname><given-names>RT</given-names></name><name><surname>Cady</surname><given-names>B</given-names></name><name><surname>Chmiel</surname><given-names>JS</given-names></name><etal></etal></person-group><article-title>National survey of carcinoma of the breast by the commission on cancer</article-title><source>J Am Coll Surg</source><year>1991</year><volume>178</volume><issue>3</issue><fpage>213</fpage><lpage>219</lpage></citation><citation citation-type="display-unstructured">Osteen RT, Cady B, Chmiel JS, et al. National survey of carcinoma of the breast by the commission on cancer. J Am Coll Surg. 1991;178(3):213–9. <pub-id pub-id-type="pmid">8149010</pub-id></citation></ref><ref id="CR2"><label>2.</label><citation citation-type="journal"><person-group person-group-type="author"><name><surname>Abu-Dalu</surname><given-names>J</given-names></name><name><surname>Weinberger</surname><given-names>E</given-names></name><name><surname>Weiss</surname><given-names>A</given-names></name><name><surname>Urca</surname><given-names>I</given-names></name></person-group><article-title>Lymphedema of the upper limb as the presenting symptom of breast carcinoma.</article-title><source>[Hebrew] Harefuah</source><year>1975</year><volume>88</volume><issue>4</issue><fpage>161</fpage><lpage>162</lpage></citation><citation citation-type="display-unstructured">Abu-Dalu J, Weinberger E, Weiss A, Urca I. Lymphedema of the upper limb as the presenting symptom of breast carcinoma. [Hebrew] Harefuah. 1975;88(4):161–2. <pub-id pub-id-type="pmid">1123194</pub-id></citation></ref><ref id="CR3"><label>3.</label><citation citation-type="journal"><person-group person-group-type="author"><name><surname>Shannon</surname><given-names>C</given-names></name><name><surname>Walsh</surname><given-names>G</given-names></name><name><surname>Sapunar</surname><given-names>F</given-names></name><name><surname>ÁHern</surname><given-names>R</given-names></name><name><surname>Smith</surname><given-names>I</given-names></name></person-group><article-title>Occult primary breast carcinoma presenting as axillary lymphadenopathy</article-title><source>Breast</source><year>2002</year><volume>11</volume><fpage>414</fpage><lpage>418</lpage><pub-id pub-id-type="doi">10.1054/brst.2002.0455</pub-id></citation><citation citation-type="display-unstructured">Shannon C, Walsh G, Sapunar F, ÁHern R, Smith I. Occult primary breast carcinoma presenting as axillary lymphadenopathy. Breast. 2002;11:414–8. <pub-id pub-id-type="pmid">14965705</pub-id></citation></ref><ref id="CR4"><label>4.</label><citation citation-type="journal"><person-group person-group-type="author"><name><surname>Humphrey</surname><given-names>LL</given-names></name><name><surname>Helfand</surname><given-names>M</given-names></name><name><surname>Chan</surname><given-names>BK</given-names></name><name><surname>Woolf</surname><given-names>SH</given-names></name></person-group><article-title>Breast cancer screening: a summary of the evidence for the U.S. Preventive Services Task Force</article-title><source>Ann Int Med</source><year>2002</year><volume>137</volume><issue>5 Part 1</issue><fpage>347</fpage><lpage>360</lpage></citation><citation citation-type="display-unstructured">Humphrey LL, Helfand M, Chan BK, Woolf SH. Breast cancer screening: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Int Med. 2002;137(5 Part 1):347–60. <pub-id pub-id-type="pmid">12204020</pub-id></citation></ref><ref id="CR5"><label>5.</label><citation citation-type="journal"><person-group person-group-type="author"><name><surname>Brill</surname><given-names>KL</given-names></name><name><surname>Brenin</surname><given-names>DR</given-names></name></person-group><article-title>Occult breast cancer and axillary mass</article-title><source>Curr Treat Options Oncol</source><year>2001</year><volume>2</volume><fpage>149</fpage><lpage>155</lpage><pub-id pub-id-type="doi">10.1007/s11864-001-0057-x</pub-id></citation><citation citation-type="display-unstructured">Brill KL, Brenin, DR. Occult breast cancer and axillary mass. Curr Treat Options Oncol. 2001;2:149–55. <pub-id pub-id-type="pmid">12057133</pub-id></citation></ref><ref id="CR6"><label>6.</label><citation citation-type="journal"><person-group person-group-type="author"><name><surname>Pfeifer</surname><given-names>RB</given-names></name><name><surname>Barber</surname><given-names>WH</given-names></name></person-group><article-title>Inflammatory breast cancer presenting with acute central venous thrombosis: a case report</article-title><source>Am Surg</source><year>2002</year><volume>68</volume><issue>6</issue><fpage>579</fpage><lpage>581</lpage></citation><citation citation-type="display-unstructured">Pfeifer RB, Barber WH. Inflammatory breast cancer presenting with acute central venous thrombosis: a case report. Am Surg. 2002;68(6):579–81. <pub-id pub-id-type="pmid">12079142</pub-id></citation></ref><ref id="CR7"><label>7.</label><citation citation-type="journal"><person-group person-group-type="author"><name><surname>Levi</surname><given-names>I</given-names></name><name><surname>Baum</surname><given-names>M</given-names></name></person-group><article-title>Mondor’s disease as a presenting symptom of breast cancer</article-title><source>BJS</source><year>1987</year><volume>74</volume><issue>8</issue><fpage>700</fpage><pub-id pub-id-type="doi">10.1002/bjs.1800740817</pub-id></citation><citation citation-type="display-unstructured">Levi I, Baum M. Mondor’s disease as a presenting symptom of breast cancer. BJS. 1987;74(8):700. </citation></ref><ref id="CR8"><label>8.</label><citation citation-type="journal"><person-group person-group-type="author"><name><surname>Fassett</surname><given-names>DR</given-names></name><name><surname>Couldwell</surname><given-names>WT</given-names></name></person-group><article-title>Metastases to the pituitary gland</article-title><source>Neurosurg Focus</source><year>2004</year><volume>16</volume><issue>4</issue><fpage>1</fpage><lpage>4</lpage></citation><citation citation-type="display-unstructured">Fassett DR, Couldwell WT. Metastases to the pituitary gland. Neurosurg Focus. 2004;16(4):1–4. <pub-id pub-id-type="pmid">15254983</pub-id></citation></ref><ref id="CR9"><label>9.</label><citation citation-type="journal"><person-group person-group-type="author"><name><surname>Hepp</surname><given-names>HH</given-names></name><name><surname>Hoos</surname><given-names>A</given-names></name><name><surname>Leppien</surname><given-names>G</given-names></name><name><surname>Wallwiener</surname><given-names>D</given-names></name></person-group><article-title>Breast cancer metastatic to the uterine cervix: analysis of a rare event</article-title><source>Cancer Inv</source><year>1999</year><volume>17</volume><issue>7</issue><fpage>468</fpage><lpage>473</lpage></citation><citation citation-type="display-unstructured">Hepp HH, Hoos A, Leppien G, Wallwiener D. Breast cancer metastatic to the uterine cervix: analysis of a rare event. Cancer Inv. 1999;17(7):468–73. </citation></ref><ref id="CR10"><label>10.</label><citation citation-type="journal"><person-group person-group-type="author"><name><surname>Drenth</surname><given-names>JP</given-names></name><name><surname>Kleijn</surname><given-names>EH</given-names></name><name><surname>Mulder</surname><given-names>PH</given-names></name><name><surname>Meer</surname><given-names>JW</given-names></name></person-group><article-title>Metastatic breast cancer presenting as fever, rash, and arthritis</article-title><source>Cancer</source><year>1995</year><volume>75</volume><issue>7</issue><fpage>1608</fpage><lpage>1611</lpage><pub-id pub-id-type="doi">10.1002/1097-0142(19950401)75:7<1608::AID-CNCR2820750709>3.0.CO;2-A</pub-id></citation><citation citation-type="display-unstructured">Drenth JP, de Kleijn EH, de Mulder PH, van der Meer JW. Metastatic breast cancer presenting as fever, rash, and arthritis. Cancer. 1995;75(7):1608–11. <pub-id pub-id-type="pmid">8826917</pub-id></citation></ref></ref-list></back></pmc></record>Pour manipuler ce document sous Unix (Dilib)
EXPLOR_STEP=$WICRI_ROOT/Wicri/Sante/explor/LymphedemaV1/Data/Pmc/Corpus
HfdSelect -h $EXPLOR_STEP/biblio.hfd -nk 001C05 | SxmlIndent | more
Ou
HfdSelect -h $EXPLOR_AREA/Data/Pmc/Corpus/biblio.hfd -nk 001C05 | SxmlIndent | more
Pour mettre un lien sur cette page dans le réseau Wicri
{{Explor lien
|wiki= Wicri/Sante
|area= LymphedemaV1
|flux= Pmc
|étape= Corpus
|type= RBID
|clé= PMC:1852908
|texte= Breast Cancer Presenting as Unilateral Arm Edema
}}
Pour générer des pages wiki
HfdIndexSelect -h $EXPLOR_AREA/Data/Pmc/Corpus/RBID.i -Sk "pubmed:17443377" \
| HfdSelect -Kh $EXPLOR_AREA/Data/Pmc/Corpus/biblio.hfd \
| NlmPubMed2Wicri -a LymphedemaV1
| This area was generated with Dilib version V0.6.31. |  |