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Azuar AS, Uzan C, Mathelin C, Vignes S. [Update of indications and techniques for the management of lymphedema after breast cancer surgery]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2024; 52:142-148. [PMID: 38190967 DOI: 10.1016/j.gofs.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 12/30/2023] [Indexed: 01/10/2024]
Abstract
OBJECTIVES Upper limb lymphedema secondary to breast cancer treatment is the leading cause of lymphedema in France. Despite improved surgical practices and de-escalation of radiotherapy, the risk of lymphedema after breast cancer still affects 5-20% of patients, with this variation depending on the measurement method used and the population studied. Lymphedema has a negative impact on quality of life and body image, and their possible occurrence remains a major concern for all women treated for breast cancer. The Sénologie Commission of the Collège national des gynécologues et obstétriciens français (CNGOF) asked four specialists in breast surgery or lymphology to prepare a summary on the prevention, medical and surgical management of lymphedema after breast cancer treatment, and to discuss the medical and surgical innovations currently being evaluated. METHODS This synthesis was based on national and international guidelines on the management of upper limb lymphedema after breast surgery and a recent review of the literature focusing on the years 2020-2023. RESULTS From a preventive point of view, the restrictive instructions imposed for a long time (reduction in physical activity or the carrying of loads, air travel, exposure to the sun or cold, etc.) have altered patients' quality of life and should no longer be recommended. A good understanding of risk factors enables us to target preventive actions. Examples include obesity, a sedentary lifestyle, axillary clearance, radiotherapy of the axillary fossa in addition to axillary clearance, total mastectomy, taxanes or anti-HER-2 therapies in the adjuvant phase. Resumption of physical activity, minimally invasive axillary surgery, de-escalation of radiotherapy and breast-conserving surgical procedures have all demonstrated their preventive value. When lymphedema does occur, early management, through complete decongestive physiotherapy, can help reduce its volume and prevent its long-term worsening. CONCLUSION Surgical (lymph node transplants, lympho-vascular anastomoses) and medical (prolymphangiogenic growth factors) approaches to lymphedema treatment are numerous, but require long-term evaluation of their efficacy and adverse effects.
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Affiliation(s)
- Anne-Sophie Azuar
- Service de chirurgie et cancérologie gynécologique et mammaire, centre hospitalier de Grasse, chemin de Clavary, 06130 Grasse, France.
| | - Catherine Uzan
- Service de chirurgie et cancérologie gynécologique et mammaire, hôpital Pitié-Salpêtrière, AP-HP, Sorbonne université, 47-83, boulevard de l'Hôpital, 75013 Paris, France.
| | - Carole Mathelin
- Service de chirurgie, ICANS, avenue Albert-Calmette, 67200 Strasbourg, France; CHRU, avenue Molière, 67200 Strasbourg, France.
| | - Stéphane Vignes
- Unité de lymphologie, Centre de référence des lymphœdèmes primaires, membre de la filière FAVA-Multi et du Réseau européen VASCERN, hôpital de Cognacq-Jay, 15, rue Eugène-Millon, 75015 Paris, France.
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Shen A, Qiang W, Zhang L, Bian J, Zhu F, Zhang Z, Lu Q. Risk Factors for Breast Cancer-Related Lymphedema: An Umbrella Review. Ann Surg Oncol 2024; 31:284-302. [PMID: 37725224 DOI: 10.1245/s10434-023-14277-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 08/25/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Identification of risk factors facilitates the prevention of breast cancer-related lymphedema (BCRL). Several published systematic reviews have already addressed the risk factors for BCRL. This study aimed to systematically identify potential risk factors for BCRL and evaluate the quality of evidence. METHODS The study followed methodologic guidance from the Joanna Briggs Institute, and the Cochrane Handbook. The following electronic databases were systematically searched from inception to 15 November 2022: PubMed, Embase, CINAHL, Web of Science, Scopus, CNKI, SinoMed, Wanfang, JBI Database, Cochrane Database, ProQuest, and PROSPERO. Two authors independently screened studies, extracted data, and assessed methodologic quality using AMSTAR2, risk of bias using ROBIS, and evidence quality using GRADE. The study evaluated overlap, assessed the small-study effect, and calculated the I2 statistic and Egger's P value as needed. RESULTS The study included 14 publications comprising 10 meta-analyses and 4 systematic reviews. The authors identified 39 factors and 30 unique meta-analyses. In the study, 13 innate personal trait-related risk factors, such as higher body mass index (BMI) and axillary lymph nodes dissection, showed statistically significant associations with BCRL incidence. Breast reconstruction was found to be a protective factor. The methodologic quality was low or critically low. The majority of the systematic reviews and/or meta-analyses were rated as having a high risk of bias. Evidence quality was low for 22 associations and moderate for 8 associations. CONCLUSIONS The currently identified risk factors for BCRL all are innate personal trait-related factors. Future well-designed studies and robust meta-analyses are needed to explore potential associations between behavioral-, interpersonal-, and environmental-related factors and BCRL, as well as the role of genetic variations and pathophysiologic factors.
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Affiliation(s)
- Aomei Shen
- Department of Nursing, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- Division of Medical and Surgical Nursing, School of Nursing, Peking University, Beijing, China
- Peking University Health Science Centre for Evidence-Based Nursing: A Joanna Briggs Institute Affiliated Group, Beijing, China
| | - Wanmin Qiang
- Department of Nursing, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Liyuan Zhang
- Department of Nursing, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Jingru Bian
- Department of Nursing, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Fei Zhu
- School of Nursing, Hebei University, Baoding, China
| | - Zijuan Zhang
- Division of Medical and Surgical Nursing, School of Nursing, Peking University, Beijing, China
- Peking University Health Science Centre for Evidence-Based Nursing: A Joanna Briggs Institute Affiliated Group, Beijing, China
| | - Qian Lu
- Division of Medical and Surgical Nursing, School of Nursing, Peking University, Beijing, China.
- Peking University Health Science Centre for Evidence-Based Nursing: A Joanna Briggs Institute Affiliated Group, Beijing, China.
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Klein I, Friger M, David MB, Shahar D. Risk factors for long-term arm morbidities following breast cancer treatments: A systematic review. Oncotarget 2023; 14:921-942. [PMID: 38039404 PMCID: PMC10691815 DOI: 10.18632/oncotarget.28539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 11/16/2023] [Indexed: 12/03/2023] Open
Abstract
PURPOSE To examine the risk factors for arm morbidity following breast cancer treatments, taking a broad view of all types of physical morbidity, including prolonged pain, lymphedema, decreased range of motion, and functional limitations. METHODS A systematic literature review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines. Studies exploring the risk factors for prolonged arm morbidity following breast cancer surgery and treatments were included. The studies were assessed independently according to pre-eligibility criteria, following data extraction and methodological quality assessment. RESULTS 1,242 articles were identified. After removing duplicates, the full texts of 1,153 articles were examined. Sixty-nine of these articles met the criteria and were included in the review. These 69 articles identified 29 risk factors for arm morbidity following treatments for breast cancer. The risk of bias was evaluated using NIH study quality assessment tools. The studies reviewed were published between 2001 and 2021 and included a total of 22,886 patients who were followed up for between three months and 10 years. CONCLUSIONS The main risk factors for long-term morbidity are removal of lymph nodes from the axilla, body mass index >30, having undergone a mastectomy, the stage of the disease, radiation therapy, chemotherapy, infection and trauma to the affected arm after surgery. An understanding of the risk factors for prolonged arm morbidity after surgery can help doctors and therapists in making personalized decisions about the need and timing of rehabilitation treatments.
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Affiliation(s)
- Ifat Klein
- Department of Physical Therapy, Assuta Medical Center, Ramat Hahayal, Tel Aviv 6971028, Israel
- Department of Epidemiology, Biostatistics and Community Health Sciences, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva 8410501, Israel
| | - Michael Friger
- Department of Epidemiology, Biostatistics and Community Health Sciences, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva 8410501, Israel
| | - Merav Ben David
- Department of Physical Therapy, Assuta Medical Center, Ramat Hahayal, Tel Aviv 6971028, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva 8410501, Israel
| | - Danit Shahar
- Department of Epidemiology, Biostatistics and Community Health Sciences, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva 8410501, Israel
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Lee KT, Kim J, Jeon BJ, Pyon JK, Bang SI, Hwang JH, Mun GH. Association of the breast reconstruction modality with the development of postmastectomy lymphedema: A long-term follow-up study. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:1177-1183. [PMID: 36964054 DOI: 10.1016/j.ejso.2023.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 01/06/2023] [Accepted: 01/24/2023] [Indexed: 02/04/2023]
Abstract
BACKGROUND Whether the breast reconstruction modality could influence the long-term development of post-mastectomy lymphedema has been little investigated. The present study aimed to evaluate the potential association of the breast reconstruction method with the incidence of lymphedema over an extended follow-up period. METHODS Patients with breast cancer who underwent immediate reconstruction from 2008 to 2014 were reviewed. They were categorized into three groups according to the reconstruction method: tissue expander/implant, abdominal flaps, and latissimus dorsi (LD) muscle flaps. Differences in the cumulative incidence of lymphedema by the reconstruction method were analyzed, as well as their independent influence on the outcome. Further analyses were conducted with propensity-score matching for baseline characteristics. RESULTS In total, 664 cases were analyzed with a median follow-up of 83 months (402 prostheses, 180 abdominal flaps, and 82 LD flaps). The rate of axillary lymph node dissection was significantly higher in the LD flap group than in the other two groups. The 5-year cumulative incidences of lymphedema in the LD flap, abdominal flap, and prosthesis groups were 3.7%, 10.6%, and 10.9%, respectively. In multivariable analyses, compared to the use of the LD flap, that of tissue expander/implant and that of abdominal flaps were associated with increased risks of lymphedema. A similar association was observed in the propensity-score matching analysis. The use of abdominal flaps or prostheses was not associated with the outcomes. CONCLUSIONS Our results suggest that the method of immediate breast reconstruction might be associated with the development of postmastectomy lymphedema.
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Affiliation(s)
- Kyeong-Tae Lee
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea
| | - Jisu Kim
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea
| | - Byung-Joon Jeon
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea
| | - Jai Kyong Pyon
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea
| | - Sa Ik Bang
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea
| | - Ji Hye Hwang
- Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea
| | - Goo-Hyun Mun
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea.
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Use of the Cephalic Vein in DIEP Breast Reconstruction Does Not Increase Risk of Lymphedema of the Ipsilateral Arm. Plast Reconstr Surg 2023; 151:195-201. [PMID: 36251837 DOI: 10.1097/prs.0000000000009769] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
SUMMARY Flap failure is a rare but devastating complication in deep inferior epigastric perforator (DIEP) flap reconstructions. Common causes of partial or complete flap failure are related to venous congestion. Although the cephalic vein is usually a safe and reliable recipient vein for additional venous outflow, there is a hypothesized risk of donor-arm lymphedema secondary to lymphatic vessel damage in the vicinity of the cephalic vein or related to scarring and reduced venous backflow of the arm. The aim was to assess whether the cephalic vein as an additional recipient vessel, by means of the superficial inferior epigastric vein in DIEP flap breast reconstruction, was associated with long-term volume changes of the arm and/or symptoms of lymphedema. Arm volume was assessed preoperatively in patients scheduled to undergo unilateral delayed DIEP flap breast reconstruction at Uppsala University Hospital, Sweden, between 2001 and 2007. Long-term postoperative assessments were performed in 2015 to 2016. Water displacement and circumferential measurement were assessed preoperatively and postoperatively by the same lymphedema therapists. Patients were divided into two groups: DIEP reconstruction with the cephalic vein or without. Fifty-four patients fulfilled the inclusion criteria and completed the study, with a mean follow-up time of 136 months. There was no increased occurrence of lymphedema in the group undergoing DIEP flap reconstruction with the cephalic vein as extra venous drainage, based on an analysis of change from baseline in arm volume difference.This study shows that the cephalic vein can be used for secondary venous outflow in DIEP breast reconstruction without long-term risk of ipsilateral arm volume increase or symptoms of lymphedema. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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Risk factors of unilateral breast cancer-related lymphedema: an updated systematic review and meta-analysis of 84 cohort studies. Support Care Cancer 2022; 31:18. [PMID: 36513801 DOI: 10.1007/s00520-022-07508-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 12/02/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE To review and update the incidence and risk factors for breast cancer-related lymphedema based on cohort studies. METHODS The study was guided by the Joanna Briggs Institute methodology and the Cochrane handbook for systematic reviews. PubMed, EMBASE, CINAHL, Scopus, Web of Science, The Cochrane Library, CNKI, SinoMed, and Wan Fang Database were searched from inception to November 15, 2021. Cohort studies reported adjusted risk factors were selected. PRISMA guideline was followed. Study quality were evaluated using the Newcastle-Ottawa scale. Random-effects models were adopted. The robustness of pooled estimates was validated by meta-regression and subgroup analysis. Lymphedema incidence and adjusted risk factors in the multivariable analyses with hazard / odds ratios and 95% CIs were recorded. RESULTS Eighty-four cohort studies involving 58,358 breast cancer patients were included. The pooled incidence of lymphedema was 21.9% (95% CI, 19.8-24.0%). Fourteen factors were identified including ethnicity (black vs. white), higher body mass index, higher weight increase, hypertension, higher cancer stage (III vs. I-II), larger tumor size, mastectomy (vs. breast conservation surgery), axillary lymph nodes dissection, more lymph nodes dissected, higher level of lymph nodes dissection, chemotherapy, radiotherapy, surgery complications, and higher relative volume increase postoperatively. Additionally, breast reconstruction surgery, and adequate finance were found to play a protective role. However, other variables such as age, number of positive lymph nodes, and exercise were not correlated with risk of lymphedema. CONCLUSION Treatment-related factors still leading the development of breast cancer-related lymphedema. Other factors such as postoperative weight increase and finance status also play a part. Our findings suggest the need to shift the focus from treatment-related factors to modifiable psycho-social-behavioral factors.
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Hirche C. [Autologous Breast Reconstruction in Conjuction with Lymphatic Microsurgery in Breast Cancer-Related Lymphedema]. HANDCHIR MIKROCHIR P 2022; 54:326-338. [PMID: 35944536 DOI: 10.1055/a-1868-5527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Breast cancer-related lymphedema of the upper extremity is the most significant non-oncological complication of tumour therapy, leading to functional impairment and impacting patients' quality of life. Autologous breast reconstruction per se effectively reduces incidence and stage of lymphedema after breast cancer treatment by surgical angiogenesis. In addition, modern surgical techniques for treating lymphedema are effective in reducing limb volume, circumference and functional impairment, and improving patients' quality of life, body image, integrity and local immunocompetence. Reconstructive surgery, including lymphovenous anastomoses (LVA) and vascularised lymph node transfer (VLNT), have been shown to rearrange or restore lymphatic flow and prevent stage progression. For patients with breast cancer-related lymphedema after mastectomy, autologous breast reconstruction in conjunction with lymphatic microsurgery using VLNT, LVA or a combination of these procedures offers the option of holistic and single-stage restoration in modern senology. Extensive scar release in the axilla is a crucial component of the surgical technique, aiming to prepare the recipient bed for the VLN transplant and to allow for the functional recruitment of remaining lymph vessels of the upper extremity. This article presents the indications, preoperative diagnostic evaluation, surgical techniques and precautions, complications and results of combined lymphatic and breast restoration.
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Affiliation(s)
- Christoph Hirche
- Abteilung für Plastische, Hand- und Rekonstruktive Mikrochirurgie, Handtrauma- und Replantationszentrum, BG Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany
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Kuruvilla AS, Krajewski A, Li X, Yang J, Mulay SR, Agha SM, Kohli HK, Bellis RM, Tannous HJ, Shroyer ALW. Risk Factors Associated With Postmastectomy Breast Cancer Lymphedema: A Multicenter Retrospective Analysis. Ann Plast Surg 2022; 88:S239-S245. [PMID: 35513327 DOI: 10.1097/sap.0000000000003107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Lymphedema is an edematous condition that afflicts the postmastectomy breast cancer population, with diminished quality of life with substantial financial costs. The factors predictive of postmastectomy lymphedema development in breast cancer patients are unknown. The objective was to evaluate the trends over time in lymphedema development and the risk factors predictive of lymphedema-related events within 2 years of mastectomy. METHODS Using the New York Statewide Planning and Research Cooperative System multicenter deidentified database from 2010 to 2016, a total of 65,543 breast cancer postmastectomy female patients (mean age, 59 ± 20 years) were identified across 177 facilities. The breast cancer patients were followed for any 2-year postmastectomy lymphedema-related events. A multivariable model identified predictors of 2-year lymphedema using eligible variables involving demographics, comorbidities, and complications. Elixhauser score was defined as a comorbidity index based on International Classification of Diseases codes used in hospital settings. RESULTS Overall, 5.2% (n = 3409) of the breast cancer postmastectomy patients experienced a lymphedema-related event within 2 years of initial surgery. Over time, 2-year postmastectomy lymphedema rates have more than doubled from 4.62% in 2010 to 9.75% in 2016 (P < 0.001). Two-year postmastectomy lymphedema rates varied significantly by mastectomy procedure type: 5.69% of the mastectomy-only procedures, 5.96% of the mastectomies with lymph node biopsies, and 7.83% of the mastectomies with lymph node dissections (P < 0.0001). Full mastectomies had a greater 2-year lymphedema rate of 7.31% when compared with partial mastectomies with 2.79% (P < 0.0001). The top predictive risk factors for a lymphedema-related event included higher Elixhauser score, prolonged hospitalization for mastectomy, more recent mastectomy procedure, obesity, younger age, non-Asian race, Medicaid insurance, and hypertension (all P's < 0.01). CONCLUSIONS Although more recent postmastectomy lymphedema rates may not be as high as historical estimates, the 2-year postmastectomy lymphedema rates have more than doubled from 2010 to 2016 requiring further elucidation as well as continued focus on treatment. Furthermore, risk factors were identified that predispose postmastectomy breast cancer patients to developing lymphedema. Given these findings, perioperative screening seems warranted to proactively identify, educate, and monitor postmastectomy patients at greatest risk of future lymphedema development.
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Affiliation(s)
- Annet S Kuruvilla
- From the Department of Surgery, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY
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Access to Physical Rehabilitation for a Range of Adverse Physical Effects Following Different Types of Breast Cancer Surgery. REHABILITATION ONCOLOGY 2022. [DOI: 10.1097/01.reo.0000000000000297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Tampaki EC, Tampakis A. Breast Reconstruction: Necessity for Further Standardization of the Current Surgical Techniques Attempting to Facilitate Scientific Evaluation and Select Tailored Individualized Procedures Optimizing Patient Satisfaction. Breast Care (Basel) 2022; 16:574-583. [PMID: 35087360 DOI: 10.1159/000518745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 07/28/2021] [Indexed: 11/19/2022] Open
Abstract
Background Various breast cancer reconstruction methods and novel surgical techniques include autologous or allogenic procedures, which can increase patient's quality of life and provide options when dealing with patients seen as challenging clinical scenarios. Summary Our aim was to review the current literature and present published evidence on innovative standards in whole breast reconstruction. Advances in flap monitoring or newly published data regarding neurotization in breast reconstruction, arm lymphedema management, breast implant-associated anaplastic large cell lymphoma reconstruction treatment, and robotic surgery with regard to radiotherapy define innovative standards in the breast reconstruction setting. The role of meshes/acellular dermal matrix and fat grafting as well as optimal sequencing of postmastectomy radiotherapy in autologous and alloplastic breast reconstruction appear highly debatable also in expert panel meetings rendering further clinical research including RCTs imperative. Key Messages There is an abundance of novel available techniques, which mandate further standardization, facilitating scientific evaluation in an attempt to help surgeons select tailored procedures for each patient with the goal to promote informed decision-making in breast reconstruction.
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Affiliation(s)
| | - Athanasios Tampakis
- Department of General and Visceral Surgery, Basel University Hospital, Basel, Switzerland
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Gowda AU, Nie J, Mets E, Alperovich M, Avraham T. Risk Factors for Lymphedema After Breast Conservation Therapy and Oncoplastic Reduction. Ann Plast Surg 2021; 87:248-252. [PMID: 33346532 DOI: 10.1097/sap.0000000000002630] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Lymphedema is a known complication after the surgical management of breast cancer, yet the incidence is poorly defined after breast conserving therapy and oncoplastic reduction. The primary aim of this study was to define lymphedema incidence in this population. Furthermore, we sought to correlate demographic factors, surgical approach, and complementary treatment modalities with incidence. METHODS Data were collected retrospectively on patients who underwent breast conserving therapy at our institution from 2012 to 2015 with greater than 1 year of follow-up. Patients were excluded if they underwent breast surgery before treatment, completion mastectomy, delayed breast reconstruction, or delayed breast reduction. RESULTS Five hundred and eighty-four patients met study criteria with a 11% lymphedema rate. Patients developing lymphedema had higher preoperative body mass index (P = 0.02), larger breast mass resection volume (P < 0.01), higher rate of axillary dissection (P < 0.01), increased rate of adjuvant whole-breast radiation (P = 0.03), supraclavicular radiation (P < 0.01), axillary radiation (P < 0.01), and neoadjuvant medical therapy (P < 0.01). Multivariate analysis showed breast specimen mass, axillary radiation, and neoadjuvant medical therapy, which were associated with lymphedema (P < 0.05). There was no difference in lymphedema incidence between partial mastectomy and oncoplastic reduction cohorts with independent multivariate analyses for each showing axillary radiation and neoadjuvant medical therapy were significantly associated with lymphedema (P < 0.05), although breast specimen mass was not. CONCLUSIONS Elevated preoperative body mass index, radiation, axillary dissection, and neoadjuvant medical therapy are associated with an increased risk of lymphedema after breast conserving surgery. Oncoplastic reconstruction is not a risk factor for lymphedema.
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Affiliation(s)
- Arvind U Gowda
- From the Department of Surgery, Yale University School of Medicine, New Haven, CT
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Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Understand the available donor sites for autologous breast reconstruction. 2. Describe the advantages and limitations of each donor site. 3. Provide a rational, algorithmic preoperative evaluation and approach for patients seeking autologous breast reconstruction. 4. Develop an effective postoperative monitoring system to minimize complications and maximize salvage of microvascular thromboses. SUMMARY Breast reconstruction remains at the heart of the field of plastic and reconstructive surgery, and it is continuously evolving. Tremendous advances in breast implant technology and supplemental products, particularly acellular dermal matrices, have revolutionized breast reconstruction in the modern era. However, microvascular free flap breast reconstruction has also witnessed profound advancements with exceptionally high success rates, with the ability to provide the most durable and natural breast reconstruction. Although the pendulum oscillates between prosthesis-based reconstruction and autologous tissue, the present synopsis will focus on autologous free flap breast reconstruction from an historical perspective, recent advancements in microsurgery, and the future of autologous breast reconstruction.
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Kim N, Kim H, Hwang JH, Park W, Cho WK, Yeo SM, Lee H, Lee SK. Longitudinal impact of postmastectomy radiotherapy on arm lymphedema in patients with breast cancer: An analysis of serial changes in arm volume measured by infrared optoelectronic volumetry. Radiother Oncol 2021; 158:167-174. [PMID: 33667586 DOI: 10.1016/j.radonc.2021.02.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 02/16/2021] [Accepted: 02/21/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE This study was conducted to evaluate the longitudinal impact of postmastectomy radiation therapy (PMRT) on persistent severe lymphedema (PSL) using arm volume measurements by an infrared optoelectronic volumetry. MATERIALS AND METHODS Of the patients who underwent mastectomy between 2008 and 2016, we included 330 patients with secondary arm lymphedema. Percentage of excessive volume (PEV) of the arm were serially assessed using an optoelectronic volumetry 1, 3, 6, 12, 18, 24, 36, and 48 months after the lymphedema diagnosis (Tlymh_Dx). We defined PSL as 2 or more episodes of PEV ≥ 20%. Risk factors for PSL were evaluated using stepwise regression analyses. RESULTS Patients who received PMRT (n = 202, 61.2%) were more likely to have larger extent of axillary node dissection (AND), and frequent stage II/III lymphedema at Tlymh_Dx than those who did not receive PMRT (p < 0.001). With a median follow-up of 72.5 months, PSL occurred in 71 (21.5%) patients. Patients with PSL were more frequently treated with AND of ≥ 20 nodes without reconstruction, had advanced lymphedema stage and higher PEV at Tlymh_Dx, and more frequent events of cellulitis compared to those without PSL. The risk of developing PSL was significantly associated with PMRT with regional node irradiation (RNI), AND of ≥20 nodes, lymphedema stage, and PEV at Tlymh_Dx, cellulitis, and compliance with physical therapy. CONCLUSION PMRT, especially RNI, was associated with a consistent increase in PEV in patients with arm lymphedema. Therefore, timely physical therapy is necessary for this patient population.
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Affiliation(s)
- Nalee Kim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Haeyoung Kim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Ji Hye Hwang
- Department of Physical & Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Won Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Won Kyung Cho
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seung Mi Yeo
- Department of Physical & Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyebin Lee
- Department of Radiation Oncology, Kangbook Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sei Kyung Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Havens LM, Brunelle CL, Gillespie TC, Bernstein M, Bucci LK, Kassamani YW, Taghian AG. Use of technology to facilitate a prospective surveillance program for breast cancer-related lymphedema at the Massachusetts General Hospital. Mhealth 2021; 7:11. [PMID: 33634194 PMCID: PMC7882272 DOI: 10.21037/mhealth-19-218] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 04/29/2020] [Indexed: 11/06/2022] Open
Abstract
Breast cancer-related lymphedema (BCRL) is a negative sequela of breast cancer (BC) caused by trauma to the lymphatic system during surgery or radiation to the axillary lymph nodes. BCRL affects approximately one in five patients treated for BC, and patients are at a lifelong risk for BCRL after treatment. Early diagnosis of BCRL may prevent its progression and reduce negative effects on quality of life, necessitating comprehensive prospective screening. This paper provides an overview of technology that may be used as part of a BCRL screening program, including objective measures such as perometry, bioimpedance spectroscopy, tissue tonometry, and three-dimensional optical imaging. Furthermore, this paper comprehensively reviews the technology incorporated into the established prospective screening program at Massachusetts General Hospital. Our prospective screening program consists of longitudinal measurements via perometry, symptoms assessment, and clinical examination by a certified lymphedema therapist (CLT) as needed. Discussion about use of perometry within the screening program and incorporation of arm volume measurements into equations to determine change over time and accurate diagnosis is included [relative volume change (RVC) and weight-adjusted change (WAC) equations]. Use of technology throughout the program is discussed, including a HIPPA-compliant online research database, the patient's electronic medical record, and incorporation of BCRL-related symptoms [BC and lymphedema symptom experience index (BCLE-SEI) survey]. Ultimately, both subjective and objective data are used to inform BCRL diagnosis and treatment by the CLT. In conclusion, the role of technology in facilitating BCRL screening is indispensable, and the continued development of objective assessment methods that are not only reliable and valid, but also cost-effective and portable will help establish BCRL screening as the standard of care for patients treated for BC.
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Affiliation(s)
- Lauren M. Havens
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Cheryl L. Brunelle
- Department of Physical and Occupational Therapy, Massachusetts General Hospital, Boston, MA, USA
| | - Tessa C. Gillespie
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Madison Bernstein
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Loryn K. Bucci
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Yara W. Kassamani
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Alphonse G. Taghian
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
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Nassif TM, Brunelle CL, Gillespie TC, Bernstein MC, Bucci LK, Naoum GE, Taghian AG. Breast Cancer-Related Lymphedema: a Review of Risk Factors, Radiation Therapy Contribution, and Management Strategies. CURRENT BREAST CANCER REPORTS 2020. [DOI: 10.1007/s12609-020-00387-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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16
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McLaughlin SA, Brunelle CL, Taghian A. Breast Cancer-Related Lymphedema: Risk Factors, Screening, Management, and the Impact of Locoregional Treatment. J Clin Oncol 2020; 38:2341-2350. [PMID: 32442064 DOI: 10.1200/jco.19.02896] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
| | - Cheryl L Brunelle
- Lymphedema Research Program, Massachusetts General Hospital, Boston, MA.,Department of Physical and Occupational Therapy, Massachusetts General Hospital, Boston, MA
| | - Alphonse Taghian
- Lymphedema Research Program, Massachusetts General Hospital, Boston, MA.,Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
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Forte AJ, Sisti A, Huayllani MT, Boczar D, Cinotto G, Ciudad P, Manrique OJ, Lu X, McLaughlin S. Lymphaticovenular anastomosis for breast cancer-related upper extremity lymphedema: a literature review. Gland Surg 2020; 9:539-544. [PMID: 32420289 DOI: 10.21037/gs.2020.03.41] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Breast cancer-related lymphedema is a long-term condition that affects almost half of breast cancer survivors. Clinical studies have looked at the benefits of lymphaticovenular anastomosis (LVA) for the treatment of upper extremities lymphedema after breast cancer, however, there is still controversy if it improves lymphedema. This study aimed to analyze the studies and outcomes related to LVA for breast cancer-related lymphedema. A PubMed/Medline search was performed using "lymphovenous bypass", "upper extremity lymphedema", "arm lymphedema after breast cancer treatment", and "lymphaticovenular anastomosis" as key words. Only English articles reporting outcomes after LVA were included. We found 22 articles that met the inclusion criteria. Positive outcomes were found in 21 studies with an objective volume reduction and subjective symptoms relief after LVA. This literature review concluded that LVA has demonstrated a significant decrease in upper extremity volumes and an improvement in subjectively reporting symptoms in breast cancer-related lymphedema patients.
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Affiliation(s)
- Antonio J Forte
- Division of Plastic Surgery Mayo Clinic, Jacksonville, FL, USA
| | - Andrea Sisti
- Division of Plastic Surgery Mayo Clinic, Jacksonville, FL, USA
| | | | - Daniel Boczar
- Division of Plastic Surgery Mayo Clinic, Jacksonville, FL, USA
| | | | - Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Oscar J Manrique
- Division of Plastic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Xiaona Lu
- Division of Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, Connecticut, USA
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Siotos C, Lagiou P, Cheah MA, Bello RJ, Orfanos P, Payne RM, Broderick KP, Aliu O, Habibi M, Cooney CM, Naska A, Rosson GD. Determinants of receiving immediate breast reconstruction: An analysis of patient characteristics at a tertiary care center in the US. Surg Oncol 2020; 34:1-6. [PMID: 32103789 DOI: 10.1016/j.suronc.2020.02.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 01/14/2020] [Accepted: 02/14/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Breast reconstruction is an option for women undergoing mastectomy for breast cancer. Previous studies have reported underutilization of reconstructive surgery. This study aims to examine the role demographic, clinical and socio-economic factors may have on patients' decisions to undergo breast reconstruction. METHODS We analyzed data from our institutional database. Using multivariable and multinomial logistic regression, we compared breast cancer patients who had undergone mastectomy-only to those who had immediate breast reconstruction (overall and by type of reconstruction). RESULTS We analyzed data on 1459 women who underwent mastectomy during the period 2003-2015. Of these, 475 (32.6%) underwent mastectomy-only and 984 (67.4%) also underwent immediate breast reconstruction. After adjusting for potential confounders, older age (OR = 0.18, 95%CI:0.08-0.40), Asian race (OR = 0.29, 95%CI:0.19-0.45), bilateral mastectomy (OR = 0.71, 95%CI:0.56-0.90), and higher stage of disease (OR = 0.44, 95%CI:0.26-0.74) were independent risk factors for not receiving immediate breast reconstruction. Furthermore, patients with Medicare or Medicaid insurance were less likely than patients with private insurance to receive an autologous reconstruction. There was no evidence for changes over time in the way socio-demographic and clinical factors were related to receiving immediate breast reconstruction after mastectomy. CONCLUSIONS Clinical characteristics, sociodemographic factors like age, race and insurance coverage affect the decision for reconstructive surgery following mastectomy.
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Affiliation(s)
- Charalampos Siotos
- Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Mikras Asias 75, Athens, 115 27, Greece; Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, 601 N. Caroline Street, Baltimore, 21287, Maryland, USA, 21287.
| | - Pagona Lagiou
- Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Mikras Asias 75, Athens, 115 27, Greece
| | - Michael A Cheah
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, 601 N. Caroline Street, Baltimore, 21287, Maryland, USA, 21287
| | - Ricardo J Bello
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, 601 N. Caroline Street, Baltimore, 21287, Maryland, USA, 21287; Department of Surgery, Johns Hopkins Hospital, 601 N. Caroline Street, Baltimore, 21287, Maryland, USA, 21287
| | - Phillipos Orfanos
- Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Mikras Asias 75, Athens, 115 27, Greece
| | - Rachael M Payne
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, 601 N. Caroline Street, Baltimore, 21287, Maryland, USA, 21287
| | - Kristen P Broderick
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, 601 N. Caroline Street, Baltimore, 21287, Maryland, USA, 21287
| | - Oluseyi Aliu
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, 601 N. Caroline Street, Baltimore, 21287, Maryland, USA, 21287
| | - Mehran Habibi
- Department of Surgery, Johns Hopkins Hospital, 601 N. Caroline Street, Baltimore, 21287, Maryland, USA, 21287
| | - Carisa M Cooney
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, 601 N. Caroline Street, Baltimore, 21287, Maryland, USA, 21287
| | - Androniki Naska
- Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Mikras Asias 75, Athens, 115 27, Greece
| | - Gedge D Rosson
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, 601 N. Caroline Street, Baltimore, 21287, Maryland, USA, 21287
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Flores AM, Nelson J, Sowles L, Stephenson RG, Robinson K, Cheville A, Sander AP, Blot WJ. Lymphedema Signs, Symptoms, and Diagnosis in Women Who Are in Minority and Low-Income Groups and Have Survived Breast Cancer. Phys Ther 2020; 100:487-499. [PMID: 32031628 PMCID: PMC7246063 DOI: 10.1093/ptj/pzaa002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 05/31/2019] [Accepted: 12/19/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Breast cancer-related lymphedema (BCRL) is a well-known side effect of cancer and its treatment with wide-ranging prevalence estimates. OBJECTIVE This study describes associations between breast cancer-related lymphedema (BCRL) signs, symptoms, and diagnosis for women who were African American, white, or had a low income and survived breast cancer. DESIGN This is a cross-sectional, observational study that used a computer-assisted telephone interview. METHODS Women who had survived breast cancer were queried on the presence of 5 lymphedema signs and symptoms (edema in the breast, axilla, arm, and/or hand; tissue fibrosis; pitting; hemosiderin staining; heaviness) and whether they had a diagnosis of BCRL. Relationships between signs/symptoms and diagnosis for each group were evaluated with kappa and chi-square statistics. RESULTS The study sample included 528 women who had survived breast cancer (266 white and 262 African American), with 514 reporting complete data on household income; 45% of the latter reported an annual household income of ≤$20,000. Women who were African American or had a low income were nearly twice as likely as women who were white to have any of 8 signs/symptoms of BCRL. Regardless of race and income, >50% of women with all BCRL signs and symptoms reported that they were not diagnosed with BCRL. LIMITATIONS The main limitations of our study are the lack of medical chart data and longitudinal design. CONCLUSIONS Women who were African American or had a low income and had survived breast cancer had a greater burden of BCRL signs and symptoms than women who were white. The lack of a strong association between BCRL signs, symptoms, and diagnosis suggests that BCRL may be underdiagnosed. These findings suggest that more rigorous screening and detection of BCRL-especially for women who are African American or have a low income-may be warranted. Cancer rehabilitation programs may be able to fill this gap.
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Affiliation(s)
- Ann Marie Flores
- Departments of Physical Therapy and Human Movement Sciences and Medical Social Sciences, Northwestern University, Chicago, Illinois; Cancer Survivorship Institute, Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL 60611 (USA),All correspondence should be addressed to Dr Flores at:
| | - Jason Nelson
- Biostatistics Research Center, Institute for Clinical Research and Health Policy Studies, Tufts University Medical Center, Boston, Massachusetts
| | | | - Rebecca G Stephenson
- Department of Rehabilitation Services, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Andrea Cheville
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota
| | - Antoinette P Sander
- Department of Physical Therapy and Human Movement Sciences and Medical Social Sciences, Northwestern University
| | - William J Blot
- International Epidemiology Institute, Rockville, Maryland; and Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee
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20
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Tastaban E, Soyder A, Aydin E, Sendur OF, Turan Y, Ture M, Bilgen M. Role of intermittent pneumatic compression in the treatment of breast cancer–related lymphoedema: a randomized controlled trial. Clin Rehabil 2019; 34:220-228. [DOI: 10.1177/0269215519888792] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Objective: To evaluate the role of intermittent pneumatic compression in the treatment of breast cancer–related lymphoedema. Design: Randomized controlled trial. Setting: Physical medicine and rehabilitation clinic at a university hospital. Subjects: Seventy-six patients with lymphoedema. Interventions: Patients were allocated into Group 1 (complex decongestive treatment, n = 38) and Group 2 (complex decongestive treatment + intermittent pneumatic compression, n = 38). The complex decongestive treatment involved skin care, manual lymphatic drainage, compression bandaging, and exercise for 20 sessions. Group 2 additionally received intermittent pneumatic compression. Main measures: Quantitative outcomes consisted of volumetric measures prior to and after the treatment. Clinical assessments included severity of pain, heaviness and tightness, disability, grip strength, and depression. Results: Lymphoedema was similar at baseline, but treatments significantly reduced the excess volume (from 373 mL to 203 mL in Group 1 and 379.5 mL to 189.5 mL in Group 2). Percentage excess volumes (PEVs) decreased in both groups. The percentage reduction of excess volume was better in Group 2 than Group 1, but the intergroup difference was not significant. The clinical scores reflected improvements, but the heaviness and tightness read significantly lower in Group 2 than Group 1. Conclusion: Intermittent pneumatic compression seems to add no benefit when combined with complex decongestive treatment of lymphoedema, but, may be functional in reducing the sensations of heaviness and tightness for the patients with pitting oedema.
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Affiliation(s)
- Engin Tastaban
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Adnan Menderes University, Aydin, Turkey
| | - Aykut Soyder
- Department of General Surgery, Faculty of Medicine, Adnan Menderes University, Aydin, Turkey
| | - Elif Aydin
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Adnan Menderes University, Aydin, Turkey
| | - Omer Faruk Sendur
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Adnan Menderes University, Aydin, Turkey
| | - Yasemin Turan
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Adnan Menderes University, Aydin, Turkey
| | - Mevlut Ture
- Department of Biostatistics, Faculty of Medicine, Adnan Menderes University, Aydin, Turkey
| | - Mehmet Bilgen
- Department of Biophysics, Faculty of Medicine, Adnan Menderes University, Aydin, Turkey
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21
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Siotos C, Azizi A, Assam L, Rosson GD, Seal SM, Pollack CE, Aliu O. Breast Reconstruction for Medicaid Beneficiaries: A Systematic Review of the Current Evidence. J Plast Surg Hand Surg 2019; 54:77-82. [PMID: 31766937 DOI: 10.1080/2000656x.2019.1688167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Introduction: Medicaid beneficiaries are a generally disadvantaged population with access to elective specialty services. We sought to better understand utilization of breast reconstruction by Medicaid beneficiaries.Methods: We systematically searched PubMed, Scopus, Web of Science, and CINAHL databases for studies comparing breast reconstruction rates by insurance type. We extracted the information of interest to qualitatively and quantitatively synthesize the results of the studies.Results: We identified seven eligible studies. Overall, the rates of breast reconstruction have increased across insurance groups. However, our results show that Medicaid beneficiaries were on average less likely to receive breast reconstruction in comparison to patients with private insurance. Although, Medicaid patients again were more likely to receive breast reconstruction in comparison to Medicare beneficiaries.Conclusion: There is wide disparity in reconstruction rates by insurance status. However, with continued increase in the adult Medicaid population due to widening eligibility expansion, disparities involving this vulnerable population should be examined for causes and solutions.
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Affiliation(s)
- Charalampos Siotos
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Armina Azizi
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Larissa Assam
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Gedge D Rosson
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Stella M Seal
- Welch Medical Library, Johns Hopkins University, Baltimore, MD, USA
| | - Craig E Pollack
- Department of General Internal Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Oluseyi Aliu
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
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22
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Survival and Disease Recurrence Rates among Breast Cancer Patients following Mastectomy with or without Breast Reconstruction. Plast Reconstr Surg 2019; 144:169e-177e. [PMID: 31348330 DOI: 10.1097/prs.0000000000005798] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Concerns have been expressed about the oncologic safety of breast reconstruction following mastectomy for breast cancer. This study aimed to evaluate the association of breast reconstruction with breast cancer recurrence, and 5-year survival among breast cancer patients. METHODS The authors analyzed data from The Johns Hopkins Hospital comprehensive cancer registry, comparing mastectomy-only to postmastectomy breast reconstruction in breast cancer patients to evaluate differences in breast cancer recurrence and 5-year survival. Kaplan-Meier curves were used to compare unadjusted estimates of survival or disease recurrence. Data were modeled through Cox proportional hazards regression, using as outcomes time to death from any cause or time to cancer recurrence. RESULTS The authors analyzed data on 1517 women who underwent mastectomy for breast cancer at The Johns Hopkins hospital between 2003 and 2015. Of these, 504 (33.2 percent) underwent mastectomy only and 1013 (66.8 percent) underwent mastectomy plus immediate breast reconstruction. Women were followed up for a median of 5.1 years after diagnosis. There were 132 deaths and 100 breast cancer recurrences. A comparison of Kaplan-Meier survival estimates demonstrated a survival benefit among patients undergoing mastectomy plus reconstruction. After adjusting for various clinical and socioeconomic variables, there was still an overall survival benefit associated with breast reconstruction which, however, was not statistically significant (hazard ratio, 0.78; 95 percent CI, 0.53 to 1.13). Patients who underwent reconstruction had a similar rate of recurrence compared to mastectomy-only patients (hazard ratio, 1.08; 95 percent CI, 0.69 to 1.69). CONCLUSION This study suggests that breast reconstruction does not have a negative impact on either overall survival or breast cancer recurrence rates. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Current Resources for Evidence-Based Practice, July 2019. J Obstet Gynecol Neonatal Nurs 2019; 48:478-491. [PMID: 31194933 DOI: 10.1016/j.jogn.2019.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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