Comparison of upper extremity lymphedema after sentinel lymph node biopsy and axillary lymph node dissection: patient-reported outcomes in 3044 patients

Protective Factors Associated with Normal Lymphatic Function After Axillary Lymph Node Dissection for Breast Cancer Treatment

BACKGROUND

Risk factors associated with developing lymphedema following axillary lymph node dissection (ALND) are well-described in the literature. However, lymphedema diagnosis criteria is arbitrary and can vary between studies. This study instead aims to identify protective factors associated with normal lymphatic function after ALND for treatment of breast cancer.

METHODS

This was a prospective study of women treated with unilateral ALND for breast cancer between 2020 and 2023. Patients with normal lymphatic function were defined as meeting all of four criteria: <10% arm volume change from baseline, <10 bioimpedance change from baseline, no compression use, and Stage 0 on ICG lymphography at one year follow-up. All other patients were classified as having abnormal lymphatic function. Univariable and multivariable logistic regression were used to examine variables possibly associated with normal lymphatic function.

RESULTS

Of 150 patients with 1-year follow-up, 39 patients (26%) had normal lymphatic function and 111 patients (74%) had abnormal lymphatic function. On multivariable analysis, immediate lymphatic reconstruction (ILR) and younger age were significantly associated with normal lymphatic function. The odds of normal lymphatic function in patients who had ILR were 2.79 times higher than that of patients who did not undergo ILR (odds ratio [OR] = 2.79, 95% confidence interval [CI] = 1.23-6.69, p = 0.017). Meanwhile, increased age was associated with decreased odds of normal lymphatic function (OR = 0.93, 95% CI = 0.89-0.97, p = 0.001).

CONCLUSIONS

Immediate lymphatic reconstruction and younger age are significantly associated with normal lymphatic function 1 year after ALND. These findings suggest that undergoing ILR may be protective against developing breast cancer-related lymphedema.

Psychological Stress and Its Correlations to Patients with Acute Lymphedema After Breast Cancer Surgery

Background

Lymphedema and psychological distress, including anxiety and depression, are common in breast cancer patients post-surgery. This study aimed to assess the incidence and determinants of anxiety and depression in patients with acute lymphedema (ALE) following breast cancer surgery.

Methods

A retrospective study was conducted on 1613 breast cancer patients who underwent surgery at Fudan University Shanghai Cancer Center in 2018. ALE was defined as lymphatic fluid accumulation causing limb swelling and was classified by the difference in arm circumference. Anxiety and depression were evaluated using the Hospital Anxiety and Depression Scale (HADS) at discharge. Descriptive statistics and logistic regression were used to identify psychological distress-related factors.

Results

Among the 1613 patients, 363 (22.5%) had ALE. Anxiety was observed in 31% and depression in 21% of patients. ALE significantly impacted anxiety in the multivariate analysis (OR = 1.57, 95% CI: [1.04-2.38], P = 0.033). Multivariate analysis of ALE patients showed that longer hospital stays (OR = 0.51, 95% CI: [0.30-0.88], P = 0.017) and invasive disease (OR = 0.39, 95% CI: [0.19-0.78], P = 0.008) were associated with reduced anxiety; while lymph-vessel invasive disease was associated with increased anxiety (OR = 5.97, 95% CI: [1.15-30.97], P = 0.034). ALE had no significant impact on depression in the multivariate analysis. However, menopause (OR = 0.72, 95% CI: [0.56-0.94], P = 0.014) and longer hospitalization (OR = 1.30, 95% CI: [1.00-1.68], P = 0.047) influenced depression in all patients. In the ALE group, lymph node surgery was the only significant factor for depression (OR = 8.67, 95% CI: [1.56-48.23], P = 0.014) in the multivariate analysis.

Conclusion

Psychological stress, influenced by both surgical factors and emotional states, is associated with ALE development. Addressing both psychological and surgical factors is crucial for improving outcomes and quality of life in post-surgery breast cancer patients.

PPARγ agonist treatment reduces fibroadipose tissue in secondary lymphedema by exhausting fibroadipogenic PDGFRα+ mesenchymal cells

Secondary lymphedema occurs in up to 20% of patients after lymphadenectomy performed for the surgical management of tumors involving the breast, prostate, uterus, and skin. Patients develop progressive edema of the affected extremity due to retention of protein-rich lymphatic fluid. Despite compression therapy, patients progress to chronic lymphedema in which noncompressible fibrosis and adipose tissue are deposited within the extremity. The presence of fibrosis led to our hypothesis that rosiglitazone, a PPARγ agonist that inhibits fibrosis, would reduce fibrosis in a mouse model of secondary lymphedema after hind limb lymphadenectomy. In vivo, rosiglitazone reduced fibrosis in the hind limb after lymphadenectomy. Our findings verified that rosiglitazone reestablished the adipogenic features of TGF-β1-treated mesenchymal cells in vitro. Despite this, rosiglitazone led to a reduction in adipose tissue deposition. Single-cell RNA-Seq data obtained from human tissues and flow cytometric and histological evaluation of mouse tissues demonstrated increased presence of PDGFRα+ cells in lymphedema; human tissue analysis verified these cells have the capacity for adipogenic and fibrogenic differentiation. Upon treatment with rosiglitazone, we noted a reduction in the overall quantity of PDGFRα+ cells and LipidTOX+ cells. Our findings provide a framework for treating secondary lymphedema as a condition of fibrosis and adipose tissue deposition, both of which, paradoxically, can be prevented with a pro-adipogenic agent.

Lymph node metastasis in cancer progression: molecular mechanisms, clinical significance and therapeutic interventions

Lymph nodes (LNs) are important hubs for metastatic cell arrest and growth, immune modulation, and secondary dissemination to distant sites through a series of mechanisms, and it has been proved that lymph node metastasis (LNM) is an essential prognostic indicator in many different types of cancer. Therefore, it is important for oncologists to understand the mechanisms of tumor cells to metastasize to LNs, as well as how LNM affects the prognosis and therapy of patients with cancer in order to provide patients with accurate disease assessment and effective treatment strategies. In recent years, with the updates in both basic and clinical studies on LNM and the application of advanced medical technologies, much progress has been made in the understanding of the mechanisms of LNM and the strategies for diagnosis and treatment of LNM. In this review, current knowledge of the anatomical and physiological characteristics of LNs, as well as the molecular mechanisms of LNM, are described. The clinical significance of LNM in different anatomical sites is summarized, including the roles of LNM playing in staging, prognostic prediction, and treatment selection for patients with various types of cancers. And the novel exploration and academic disputes of strategies for recognition, diagnosis, and therapeutic interventions of metastatic LNs are also discussed.

Risk of Lymphedema and Death after Lymph Node Dissection with Neoadjuvant and Adjuvant Treatments in Patients with Breast Cancer: An Eight-Year Nationwide Cohort Study

Knowledge on the impact of neoadjuvant and adjuvant treatments on post-surgery lymphedema (LE) in patients with breast cancer is limited due to methodological limitations and an insufficient sample size. We investigated the risk of LE in patients going through long-term anticancer treatment regimens using a national cohort from the Korean National Health Insurance Service database from 2011-2013. Incidence rate ratio, Kaplan-Meier analysis, and Cox proportional regression analysis were performed. A total of 39,791 patients were included. While minimal lymph node dissection (SLNB) reduced the risk of LE (hazard ratio [HR] 0.51) as expected, neoadjuvant chemotherapy (NAC) followed by SLNB did not reduce the risk. Adjusting for adjuvant chemotherapy (AC) as time-varying exposure decreased the risk of LE in the SLNB group (HR 0.51), but not the mortality risk (HR 0.861). A longer duration of NAC, especially taxane-based, combined with SLNB reversed the effect and increased risk of LE. The findings highlight the importance of not only early surveillance before and after surgery, but also long-term surveillance during adjuvant treatment by surgeons and oncologists in order to reduce the risk of LE.

Impact of sentinel lymph node biopsy through the axillary cribriform fascia approach on intraoperative indicators and postoperative complications

The aim of this study was to compare intraoperative indicators and postoperative complications of sentinel lymph node biopsy (SLNB) via the axillary cribriform membrane and traditional axillary fold with blue dye to make a priority choice. This single-center, retrospective cohort study enrolled 330 eligible breast cancer patients with stage of cTis ~ ₂N₀M₀ in our hospital from August 2018 to July 2021. Multiple linear and binary logistic regression were used to evaluate the effects of different surgical approaches on intraoperative indicators (drainage volume, tube time, intraoperative bleeding, operative time and the number of sentinel lymph nodes (SLNs)) and postoperative complications (upper limb edema and dysfunction). All statistical tests were two sided. Multiple linear and logistic regression results after adjusting the covariate showed that the axillary cribriform fascia approach could render more greater intraoperative indictors and reduce the risk of upper limb dysfunction (P = 0.038, OR 0.32, 95%CI 0.11-0.94). High BMI could increase the drainage volume, tube time and operative time. There was no significant difference in the number of SLNs between the two approaches and it also had no relationship with intraoperative indicators and postoperative complications. Overall, 6 (1.8%) experienced upper limb edema and 18 (5.5%) experienced upper limb dysfunction. Univariate logistic regression analysis showed that radiotherapy increased the risk of upper limb edema (P = 0.032, OR = 12.76, 95%CI 1.25-130.06). SLNB through the axillary cribriform fascia approach produces more satisfied intraoperative indictors, a lower risk of upper limb dysfunction.