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Fibro-Lipo-Lymph-Aspiration With a Lymph Vessel Sparing Procedure to Treat Advanced Lymphedema After Multiple Lymphatic-Venous Anastomoses. Ann Plast Surg 2017; 78:184-190. [DOI: 10.1097/sap.0000000000000853] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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DiSipio T, Rye S, Newman B, Hayes S. Incidence of unilateral arm lymphoedema after breast cancer: a systematic review and meta-analysis. Lancet Oncol 2013; 14:500-15. [PMID: 23540561 DOI: 10.1016/s1470-2045(13)70076-7] [Citation(s) in RCA: 1039] [Impact Index Per Article: 94.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The body of evidence related to breast-cancer-related lymphoedema incidence and risk factors has substantially grown and improved in quality over the past decade. We assessed the incidence of unilateral arm lymphoedema after breast cancer and explored the evidence available for lymphoedema risk factors. METHODS We searched Academic Search Elite, Cumulative Index to Nursing and Allied Health, Cochrane Central Register of Controlled Trials (clinical trials), and Medline for research articles that assessed the incidence or prevalence of, or risk factors for, arm lymphoedema after breast cancer, published between Jan 1, 2000, and June 30, 2012. We extracted incidence data and calculated corresponding exact binomial 95% CIs. We used random effects models to calculate a pooled overall estimate of lymphoedema incidence, with subgroup analyses to assess the effect of different study designs, countries of study origin, diagnostic methods, time since diagnosis, and extent of axillary surgery. We assessed risk factors and collated them into four levels of evidence, depending on consistency of findings and quality and quantity of studies contributing to findings. FINDINGS 72 studies met the inclusion criteria for the assessment of lymphoedema incidence, giving a pooled estimate of 16.6% (95% CI 13.6-20.2). Our estimate was 21.4% (14.9-29.8) when restricted to data from prospective cohort studies (30 studies). The incidence of arm lymphoedema seemed to increase up to 2 years after diagnosis or surgery of breast cancer (24 studies with time since diagnosis or surgery of 12 to <24 months; 18.9%, 14.2-24.7), was highest when assessed by more than one diagnostic method (nine studies; 28.2%, 11.8-53.5), and was about four times higher in women who had an axillary-lymph-node dissection (18 studies; 19.9%, 13.5-28.2) than it was in those who had sentinel-node biopsy (18 studies; 5.6%, 6.1-7.9). 29 studies met the inclusion criteria for the assessment of risk factors. Risk factors that had a strong level of evidence were extensive surgery (ie, axillary-lymph-node dissection, greater number of lymph nodes dissected, mastectomy) and being overweight or obese. INTERPRETATION Our findings suggest that more than one in five women who survive breast cancer will develop arm lymphoedema. A clear need exists for improved understanding of contributing risk factors, as well as of prevention and management strategies to reduce the individual and public health burden of this disabling and distressing disorder. FUNDING The National Breast Cancer Foundation, Australia.
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Affiliation(s)
- Tracey DiSipio
- School of Public Health and Social Work, Institute of Health and Biomedical Innovation, Queensland University of Technology, Queensland, Australia.
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Bevilacqua JLB, Kattan MW, Changhong Y, Koifman S, Mattos IE, Koifman RJ, Bergmann A. Nomograms for Predicting the Risk of Arm Lymphedema after Axillary Dissection in Breast Cancer. Ann Surg Oncol 2012; 19:2580-9. [DOI: 10.1245/s10434-012-2290-x] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Indexed: 12/30/2022]
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Langer I, Guller U, Berclaz G, Koechli OR, Schaer G, Fehr MK, Hess T, Oertli D, Bronz L, Schnarwyler B, Wight E, Uehlinger U, Infanger E, Burger D, Zuber M. Morbidity of sentinel lymph node biopsy (SLN) alone versus SLN and completion axillary lymph node dissection after breast cancer surgery: a prospective Swiss multicenter study on 659 patients. Ann Surg 2007; 245:452-61. [PMID: 17435553 PMCID: PMC1877006 DOI: 10.1097/01.sla.0000245472.47748.ec] [Citation(s) in RCA: 253] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To assess the morbidity after sentinel lymph node (SLN) biopsy compared with SLN and completion level I and II axillary lymph node dissection (ALND) in a prospective multicenter study. SUMMARY BACKGROUND DATA ALND after breast cancer surgery is associated with considerable morbidity. We hypothesized: 1) that the morbidity in patients undergoing SLN biopsy only is significantly lower compared with those after SLN and completion ALND level I and II; and 2) that SLN biopsy can be performed with similar intermediate term morbidity in academic and nonacademic centers. METHODS Patients with early stage breast cancer (pT1 and pT2 <or= 3 cm, cN0) were included between January 2000 and December 2003 in this prospective Swiss multicenter study. All patients underwent SLN biopsy. In all patients with SLN macrometastases and most patients with SLN micrometastases (43 of 68) or isolated tumor cells (11 of 19), a completion ALND was performed. Postoperative morbidity was assessed based on a standardized protocol. RESULTS SLN biopsy alone was performed in 449 patients, whereas 210 patients underwent SLN and completion ALND. The median follow-ups were 31.0 and 29.5 months for the SLN and SLN and completion ALND groups, respectively. Intermediate-term follow-up information was available from 635 of 659 patients (96.4%) of enrolled patients. The following results were found in the SLN versus SLN and completion ALND group: presence of lymphedema (3.5% vs. 19.1%, P < 0.0001), impaired shoulder range of motion (3.5% vs. 11.3%, P < 0.0001), shoulder/arm pain (8.1% vs. 21.1%, P < 0.0001), and numbness (10.9% vs. 37.7%, P < 0.0001). No significant differences regarding postoperative morbidity after SLN biopsy were noticed between academic and nonacademic hospitals (P = 0.921). CONCLUSIONS The morbidity after SLN biopsy alone is not negligible but significantly lower compared with level I and II ALND. SLN biopsy can be performed with similar short- and intermediate-term morbidity in academic and nonacademic centers.
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Affiliation(s)
- Igor Langer
- Department of Surgery, University Hospital Basel, Basel, Switzerland
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Abstract
The approach towards axillary surgery should be selective and flexible, with its management tailored to patient choice and tumour characteristics, and concordant with local practice guidelines and available resources. Sentinel-lymph-node biopsy has been embraced as a standard of care in many centres around the world and has revolutionised management of the axilla during the past decade. Nonetheless, data for long-term outcomes remain scarce, and there are persistent variations in practice and inconsistencies in methodology. An international perspective has been sought on important issues relating to management of the axilla, which includes not only the indications and techniques for sentinel-lymph-node biopsy, but also lymph-node sampling, axillary-lymph-node dissection, and observation alone. In this Review, we initially present an overview, which focuses on biological models of lymphatic networks within the breast and patterns of tumour dissemination. A set of key questions are posed with preliminary comments from the authors, followed by a series of collective viewpoints from experts within several different countries.
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Mathew J, Barthelmes L, Neminathan S, Crawford D. Comparative study of lymphoedema with axillary node dissection versus axillary node sampling with radiotherapy in patients undergoing breast conservation surgery. Eur J Surg Oncol 2006; 32:729-32. [PMID: 16777367 DOI: 10.1016/j.ejso.2006.04.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2006] [Accepted: 04/27/2006] [Indexed: 10/24/2022] Open
Abstract
AIMS Our aim was to compare the incidence of lymphoedema in two groups of patients undergoing breast conservation surgery; one undergoing axillary sampling and radiotherapy to patients with positive axillary nodes, and the other undergoing axillary clearance. METHODS Retrospective review of records of two sequential groups of patients; one undergoing axillary sampling between January 1994 and December 1998 (Group 1) and the other undergoing axillary clearance between January 2000 and December 2002 (Group 2). Both groups had minimum of 2 years follow-up. RESULTS Three hundred and twelve patients were included in Group 1 and 194 in Group 2. 2.2% of the patients in Group 1 developed lymphoedema compared to 12.3% in Group 2. This was statistically significant with a P value=0.0001. In the node-positive patients, the incidence of lymphoedema in Group 1 was 6.2% compared to 15.4% in Group 2, although the differences were not statistically significant with P=0.17. CONCLUSIONS The incidence of lymphoedema in the axillary sampling group was low, although the differences were less pronounced in the node-positive patients. The effectiveness of radiotherapy as an alternative to full axillary dissection among patients with positive nodes is currently under investigation in randomised controlled trials.
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Affiliation(s)
- J Mathew
- Ysbyty Gwynedd, Bangor, Gwynedd, North Wales, UK.
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Tanaka K, Yamamoto D, Kanematsu S, Okugawa H, Kamiyama Y. A four node axillary sampling trial on breast cancer patients. Breast 2006; 15:203-9. [PMID: 16061382 DOI: 10.1016/j.breast.2005.04.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2005] [Revised: 04/19/2005] [Accepted: 04/28/2005] [Indexed: 10/25/2022] Open
Abstract
The surgical management of axillary lymph nodes in early breast cancer remains controversial, although several maneuvers have been developed such as axillary node clearance (ANC), four node axillary sampling (4NAS), and sentinel node biopsy. A total of 237 cases of primary breast cancer at stages I and II were studied prospectively to elucidate the correlation between 4NAS and ANC. All calculated values by 4NAS showed high sensitivity, specificity, and overall accuracy as follows in this study: 92.9%, 100% and 98.5% for stage I, and 93.8%, 100% and 98.3% for stage II. Likewise, the false negative (FN) rates were 7.1% for stage I, 6.3% for stage II, 6.7% for T1, 6.4% for T2, 7.4% for N0, 0% for N1, and 6.5% for all cases. These rates were very low, although 7.4% for N0 and 0% for N1 were quite clearly different. This implies that all FN cases were N0, and were caused by micrometastases with normal consistency and size. 4NAS may be as accurate a procedure as ANC in assessing axillary nodal stage.
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Affiliation(s)
- Kanji Tanaka
- Department of Surgery, Kansai Medical University, 10-15, Fumizono, Moriguchi, Osaka 570-8507, Japan.
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Wilke LG, McCall LM, Posther KE, Whitworth PW, Reintgen DS, Leitch AM, Gabram SGA, Lucci A, Cox CE, Hunt KK, Herndon JE, Giuliano AE. Surgical complications associated with sentinel lymph node biopsy: results from a prospective international cooperative group trial. Ann Surg Oncol 2006; 13:491-500. [PMID: 16514477 DOI: 10.1245/aso.2006.05.013] [Citation(s) in RCA: 398] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2005] [Accepted: 11/09/2005] [Indexed: 11/18/2022]
Abstract
BACKGROUND American College of Surgeons Oncology Group Z0010 is a prospective multicenter trial designed to evaluate the prognostic significance of micrometastases in the sentinel lymph nodes and bone marrow aspirates of women with early-stage breast cancer. Surgical complications associated with the sentinel lymph node biopsy surgical procedure are reported. METHODS Eligible patients included women with clinical T1/2N0M0 breast cancer. Surgical outcomes were available at 30 days and 6 months after surgery for 5327 patients. Patients who had a failed sentinel node mapping (n=71, 1.4%) or a completion lymph node dissection (n=814, 15%) were excluded. Univariate and multivariate analyses were performed to identify predictors for the measured surgical complications. RESULTS In patients who received isosulfan blue dye alone (n=783) or a combination of blue dye and radiocolloid (n=4192), anaphylaxis was reported in .1% of subjects (5 of 4975). Other complications included axillary wound infection in 1.0%, axillary seroma in 7.1%, and axillary hematoma in 1.4% of subjects. Only increasing age and an increasing number of sentinel lymph nodes removed were significantly associated with an increasing incidence of axillary seroma. At 6 months, 8.6% of patients reported axillary paresthesias, 3.8% had a decreased upper extremity range of motion, and 6.9% demonstrated proximal upper extremity lymphedema (change from baseline arm circumference of >2 cm). Significant predictors for surgical complications at 6 months were a decreasing age for axillary paresthesias and increasing body mass index and increasing age for upper extremity lymphedema. CONCLUSIONS This study provides a prospective assessment of the sentinel lymph node biopsy procedure, as performed by a wide range of surgeons, demonstrating a low complication rate.
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Affiliation(s)
- Lee Gravatt Wilke
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
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Abstract
Lymphoedema is a problem frequently encountered by professionals working in palliative care. This article reviews the evidence on the magnitude of the problem of lymphoedema in the general population and provides evidence on specific high risk groups within it. Prevalence is a good indicator of the burden of disease for chronic problems such as lymphoedema, as it indicates the numbers of patients who require care. Incidence is indicative of changes in the causes of lymphoedema and the success of any prevention programmes. Both are important means of assessing the current level of need and the potential for the changing needs in managing this condition. Problems exist in all studies in relation to precise definitions of lymphoedema, inconsistent measures to assess differential diagnosis and poorly defined populations. While there is some evidence of high rates in relation to breast cancer therapy, the total burden of lymphoedema in the general population is largely unknown.
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Affiliation(s)
- Anne F Williams
- Centre for Research and Implementation of Clinical Practice, Thames Valley University, London, UK
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Langer I, Kocher T, Guller U, Torhorst J, Oertli D, Harder F, Zuber M. Long-term outcomes of breast cancer patients after endoscopic axillary lymph node dissection: a prospective analysis of 52 patients. Breast Cancer Res Treat 2005; 90:85-91. [PMID: 15770531 DOI: 10.1007/s10549-004-3268-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Reports on long-term outcomes after endoscopic axillary lymph node dissection (ALND) of breast cancer patients are still lacking in the medical literature. The objective of this prospective study was to assess the oncological and functional outcomes in breast cancer patients after endoscopic ALND. METHODS Fifty-five breast cancer patients were prospectively enrolled, of whom 52 were available for follow-up with a median of 71.9 months (range 11-96). The following oncological and functional endpoints were evaluated during follow-up at several time points: occurrence of local, axillary and distant metastases, seroma or infection, shoulder mobility (range of motion), numbness, pain, presence of lymphoedema as well as restriction in activities of daily living. RESULTS In 52 patients endoscopic ALND of level I and II was successfully performed. Two port-site metastases (2/52, 4%) occurred, one of which in a patient with negative axillary lymph nodes. The same patient suffered from the only axillary recurrence (1/52, 2%). Three patients (3/52, 6%) developed lymphoedema. No other functional adverse events (shoulder mobility, pain, numbness, hypertrophic scar) were noticed at the end of the observation period. CONCLUSION The present investigation with long-term follow-up after endoscopic ALND--the first one in the literature--reveals minor morbidity, good functional and cosmetic results. In contrary to conventional surgery, the endoscopic procedure is associated with the occurrence of port-site metastases, not seen in the open approach. Axillary recurrences do not appear more frequently when compared with results after conventional ALND. In the meantime the less invasive sentinel lymph node (SLN) biopsy is the established standard technique in evaluating the axillary lymph node status.
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Affiliation(s)
- I Langer
- Department of Surgery, University Hospital Basel, Spitalstrasse 21, CH-4031, Basel, Switzerland.
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Rönkä R, von Smitten K, Tasmuth T, Leidenius M. One-year morbidity after sentinel node biopsy and breast surgery. Breast 2005; 14:28-36. [PMID: 15695078 DOI: 10.1016/j.breast.2004.09.010] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Posttreatment morbidity within 1 year after sentinel node biopsy was evaluated objectively by physical examination and also by evaluating patients self-reports of symptoms in a questionnaire. These patients were compared with patients who underwent axillary clearance. At 2 weeks after surgery patients who had undergone sole sentinel node biopsy had made significantly better recoveries than those who had undergone axillary clearance. Although every fourth patient complained of at least mild arm symptoms 1 year after sole SNB, the risk of severe long-term morbidity is minimal. In particular, the risk of disabling lymphoedema seems to be negligible after SNB only.
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Affiliation(s)
- R Rönkä
- Breast Surgery Unit, Helsinki University Hospital, Helsinki, Finland.
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Affiliation(s)
- Julie-Ann MacLaren
- European Institute of Health and Medical Science, University of Surrey, Guildford GU2 5XH, UK.
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Damera A, Evans AJ, Cornford EJ, Wilson ARM, Burrell HC, James JJ, Pinder SE, Ellis IO, Lee AHS, Macmillan RD. Diagnosis of axillary nodal metastases by ultrasound-guided core biopsy in primary operable breast cancer. Br J Cancer 2003; 89:1310-3. [PMID: 14520465 PMCID: PMC2394321 DOI: 10.1038/sj.bjc.6601290] [Citation(s) in RCA: 113] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The purpose of this study was to examine the use of ultrasound (US)-guided core biopsy of axillary nodes in patients with operable breast cancer. The ipsilateral axillae of 187 patients with suspected primary operable breast cancer were scanned. Nodes were classified based on their shape and cortical morphology. Abnormal nodes underwent US-guided core biopsy/fine needle aspiration (FNA), and the results correlated with subsequent axillary surgery. The nodes were identified on US in 103 of 166 axillae of patients with confirmed invasive carcinoma. In total, 54 (52%) met the criteria for biopsy: 48 core biopsies (26 malignant, 20 benign node, two normal) and six FNA were performed. On subsequent definitive histological examination, 64 of 166 (39%) had axillary metastases. Of the 64 patients with involved nodes at surgery, preoperative US identified nodes in 46 patients (72%), of which 35 (55%) met the criteria for biopsy and 27 (42%) of these were diagnosed preoperatively by US-guided biopsy. In conclusion, US can identify abnormal nodes in patients presenting with primary operable breast cancer. In all, 65% of these nodes are malignant and this can often be confirmed with US-guided core biopsy.
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Affiliation(s)
- A Damera
- Department of Radiology, Helen Garrod Breast Screening Unit, Nottingham International Breast Education Centre, Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB, UK
| | - A J Evans
- Department of Radiology, Helen Garrod Breast Screening Unit, Nottingham International Breast Education Centre, Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB, UK
- Department of Radiology, Helen Garrod Breast Screening Unit, Nottingham International Breast Education Centre, Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB, UK. E-mail:
| | - E J Cornford
- Department of Radiology, Helen Garrod Breast Screening Unit, Nottingham International Breast Education Centre, Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB, UK
| | - A R M Wilson
- Department of Radiology, Helen Garrod Breast Screening Unit, Nottingham International Breast Education Centre, Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB, UK
| | - H C Burrell
- Department of Radiology, Helen Garrod Breast Screening Unit, Nottingham International Breast Education Centre, Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB, UK
| | - J J James
- Department of Radiology, Helen Garrod Breast Screening Unit, Nottingham International Breast Education Centre, Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB, UK
| | - S E Pinder
- Department of Histopathology, Nottingham City Hospital, Nottingham NG5 1PB, UK
| | - I O Ellis
- Department of Histopathology, Nottingham City Hospital, Nottingham NG5 1PB, UK
| | - A H S Lee
- Department of Histopathology, Nottingham City Hospital, Nottingham NG5 1PB, UK
| | - R D Macmillan
- Department of Breast Surgery, Nottingham City Hospital, Nottingham NG5 1PB, UK
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