Analysis of factors contributing to severity of breast cancer-related lymphedema

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.

Lymphovenous Bypass for Immediate Lymphatic Reconstruction in Breast Cancer Patients Undergoing Axillary Lymph Node Dissection: Minimizing the Risk of Upper Extremity Lymphedema

BACKGROUND

 Studies have shown a significant reduction in breast cancer-related lymphedema (BCRL) rates in patients undergoing complete axillary lymph node dissection (cALND) combined with immediate lymphatic reconstruction (ILR) using lymphovenous bypass (LVB).The purpose of this study was to determine if ILR with LVB at the time of cALND results in a decreased incidence of BCRL and its impact on patient quality of life (QOL).

METHODS

 In this prospective cohort study, patients ≥ 18 years requiring cALND underwent ILR from 2019 to 2021. The primary outcome was bilateral upper limb volumes measured by Brørson's truncated cone formula and the Pero-System (3D Körper Scanner). The secondary outcome was QOL measured by the Lymphedema Quality of Life (LYMQOL) arm patient-reported outcome measurement.

RESULTS

 Forty-two patients consented to ILR using LVB. ILR was completed in 41 patients with a mean of 1.9 ± 0.9 lymphovenous anastomosis performed. Mean age of patients was 52.4 ± 10.5 years with a mean body mass index of 27.5 ± 4.9 kg/m2. All patients (n = 39, 100%) received adjuvant therapy after ILR. Mean follow-up was 15.2 ± 5.1 months. Five patients met criteria for lymphedema throughout the duration of the study (12.8%), with two patients having resolution, with an overall incidence of 7.7% by the end of the study period. Patients with lymphedema were found to have statistically significant lower total LYMQOL values at 18 months (8.44 ± 1.17 vs. 3.23 ± 0.56, p < 0.001). A mean increase of 0.73 ± 3.5 points was observed for overall QOL average for upper limb function at 18 months compared with 3 months (t = 0.823, p = 0.425).

CONCLUSION

 This study showed an incidence of 7.7% lymphedema development throughout the duration of study. We also showed that ILR has the potential to reduce the significant long-term adverse outcomes of lymphedema and improve QOL for patients undergoing cALND.

Supraclavicular Irradiation Induces Lymphedema in Breast Cancer Patients Treated with Axillary Lymph Node Dissection and Taxane-Containing Chemotherapy

Purpose

Breast cancer-related lymphedema (LE) significantly impairs the patients' quality of life. Axillary lymph node dissection (ALND) is a strong risk factor for LE in breast cancer surgery. In addition, postoperative administration of docetaxel (DTX) has been reported to be a risk factor for LE in patients who undergo ALND. Herein, we performed the risk of objective LE after ALND.

Methods

Patients who visited the medical follow-up clinic between 12 November 2018 and 11 January 2019 and at least one year postoperatively were eligible for this study. The risk factors for objective LE according to taxane-containing regimen, radiation therapy, and body mass index and the effects of a taxane-containing regimen followed by supraclavicular irradiation on LE were examined.

Results

A total of 214 patients were included in this analysis, and objective LE was observed in 52 patients (24%). Univariate and multivariate analyses showed that only supraclavicular field irradiation was a statistically significant risk factor for objective LE. In addition, the sequential use of taxane-containing regimens and supraclavicular RT was shown to be a more likely risk factor for LE than ALND alone. We also compared each taxane regimen with supraclavicular RT and found that DTX was more likely to be a risk factor for LE in cases of sequential use of supraclavicular RT than with ALND alone. However, when comparing DTX with supraclavicular RT and PTX with supraclavicular RT directly, there was no statistically significant difference in the risk of objective LE between the two groups.

Conclusion

The risk for LE was more likely to be higher with the sequential use of taxane-containing chemotherapy and supraclavicular field irradiation. Therefore, management of LE is important in these cases.

Analysis of the Risk Factors of Breast Cancer-Related Lymphedema and Construction and Evaluation of a Prediction Model

Objective: The occurrence of breast cancer-related lymphedema (BCRL) in postoperative breast cancer survivors is described and the independent risk factors of BCRL are analyzed. A BCRL nomogram prediction model is constructed, and its effectiveness is evaluated to screen out high-risk patients with BCRL. Methods: A univariate analysis was carried out to determine the risk factors possibly related to BCRL, and a logistic regression analysis was utilized to determine the independent risk factors related to BCRL. A BCRL nomogram prediction model was built, and a nomogram was drawn by R software v4.1.0. The area under the curve (AUC) of the receiver operating characteristic (ROC) and the Hosmer-Lemeshow test were used to evaluate the efficacy of the constructed model to assess its clinical application value. Results: The risk factors independently associated with BCRL were body mass index (BMI), handedness on the operation side, no BCRL-related rehabilitation plan, axillary lymph node dissection (ALND), taxane-based chemotherapy, and radiotherapy (all p < 0.05). The BCRL nomogram prediction model was built on this basis, and the results of the efficacy evaluation showed a good fit: AUC = 0.952 (95% confidence interval: 0.930-0.973) for the ROC and χ2 = 6.963, p = 0.540 for the Hosmer-Lemeshow test. Conclusions: The risk factors for BCRL included higher BMI, handedness on the operation side, no BCRL-related rehabilitation plan, ALND, taxane-based chemotherapy, and radiotherapy. In addition, the BCRL nomogram prediction model accurately calculated the risk of possible BCRL among breast cancer survivors and effectively screened for high-risk patients with BCRL. Therefore, this prediction model can provide a basis for rehabilitation physicians and therapists to formulate early and individualized prevention and treatment programs.

The Development of Breast Cancer-Related Lymphedema After Mastectomy in a Rural Population

Breast cancer-related lymphedema (BCRL) is a lifelong condition that can impact the quality of life, affecting approximately 20% of breast cancer patients. Risk factors for the development of BCRL after mastectomy in rural populations have not been studied.Retrospective review of mastectomy patients from 2017 to 2021 was performed at a single institution. Statistical analysis included logistic and linear regression models.475 patients were included, and 40 (8.4%) patients were diagnosed with BCRL. Increased odds of developing BCRL were significantly associated with tumor-involved lymph nodes, radiation therapy, axillary lymphadenectomy, adjuvant chemotherapy, and endocrine therapy. Postmastectomy reconstruction significantly reduced the odds of developing BCRL. There was no significant association in our population with age, body mass index, diabetes, tobacco use, cancer type, or complications.This study demonstrates that individuals underrepresented in the literature, such as patients in largely rural communities, have some differences in risk factors for developing BCRL when compared to national studies.

A new severity classification of lower limb secondary lymphedema based on lymphatic pathway defects in an indocyanine green fluorescent lymphography study

Most protocols for lymphatic imaging of the lower limb conventionally inject tracer materials only into the interdigital space; however, recent studies indicate that there are four independent lymphatic vessel groups (anteromedial, anterolateral, posteromedial, and posterolateral) in the lower limb. Thus, three additional injection sites are needed for lymphatic imaging of the entire lower limb. We aimed to validate a multiple injection designed protocol and demonstrate its clinical benefits. Overall, 206 lower limbs undergoing indocyanine green fluorescent lymphography with the new injection protocol were registered retrospectively. To assess the influence of predictor variables on the degree of severity, multivariable logistic regression models were used with individual known risk factors. Using a generalized linear model, the area under the curve (AUC) of the conventional clinical model, comprising known severity risk factors, was compared with that of the modified model that included defects in the posterolateral and posteromedial groups. Multivariable logistic regression models showed a significant difference for the posteromedial and posterolateral groups. The AUC of the modified model was significantly improved compared to that of the conventional clinical model. Finding defects in the posteromedial and posterolateral groups is a significant criterion for judging lymphedema severity and introducing a new lymphedema severity classification.

Study protocol for a 10-year prospective observational study, examining lymphoedema and patient-reported outcome after breast reconstruction

INTRODUCTION

Over the last decades, treatment of breast cancer has become increasingly more effective. Consequently, an increasing number of women are living with late effects of breast cancer treatment, including disfiguring scars, deformity or asymmetry of the breast, secondary lymphoedema and other physical and psychosocial late effects. Data from this study will provide knowledge on how to guide breast reconstruction in the future towards outcomes with fewer complications, higher long-term quality of life (QoL) and satisfaction with the aesthetic outcome. The development of secondary lymphoedema, for which the effect of breast reconstruction has yet to be established, will be thoroughly examined.

METHODS AND ANALYSIS

Women receiving breast reconstruction (autologous and implant based) at the Department of Plastic Surgery and Burns Treatment, Rigshospitalet, will be invited to participate. The patients will be followed for 10 years postoperatively. Demographic, health-related, oncological characteristics and treatment data will be registered. Validated assessment tools, such as the BREAST-Q and Beck Depression Inventory, will be used to measure an extensive range of clinical outcomes, including QoL, life and aesthetic satisfaction and depression. Arm range of motion will be measured with a goniometer and lymphoedema by bioimpedance spectroscopy, compared with circular arm measurements.

ETHICS AND DISSEMINATION

This study will be conducted according to the 5th version of the Helsinki Declaration. The regional ethical committee for Capital Region Denmark did not find the study notifiable, according to the law of the committee § 1, part 4. All data will be anonymised before its publication. This study will be conducted according to the Danish data protection regulation and is catalogued and approved by the Capital Region Head of Knowledge Centre. According to the Danish health law § 46, part 2, this study does not need the Danish Patient Safety Authority's approval. The findings of this study will be submitted to international peer-reviewed journals.

Correlation of older age with severity of lymphedema in breast cancer survivors: A systematic review

BACKGROUND

Breast cancer is the most frequent cause of secondary lymphedema. Besides being progressive and chronic, lymphedema is usually hard to treat. That is why the clinicians are more focused on the prevention of its development and progression.

OBJECTIVE

The aim of this study is to evaluate the possible relationship between the age of patients and the severity of breast cancer-related lymphedema (BCRL).

METHODS

PubMed, Scopus, and Ovid MEDLINE databases were searched for articles, which described the relationship between aging and BCRL development. Two authors searched for and selected articles independently.

RESULTS

Out of 562 studies selected, 8 studies met the inclusion criteria. However, 2 papers had the same study population, so only 7 were included in the final analysis. The total number of patients in those 7 studies was 3,904. Five out of 7 studies included in our review depicted the association of more severe forms of BCRL with older age.

CONCLUSION

The final analysis showed that aging is related to the severity of BCRL. However, due to heterogeneity in study outcome reporting, the cause and effect relationship could not be determined.

Prevalence and predictors of breast cancer-related arm lymphedema over a 10-year period in postoperative breast cancer patients: A cross-sectional study

PURPOSE

Breast cancer (BC) survivors have a lifelong risk of developing lymphedema. This study investigated the prevalence of BC-related arm lymphedema among Chinese BC survivors diagnosed in the last 10 years and examined the demographic and clinical variables as well as lifestyle factors associated with lymphedema status.

METHODS

In this cross-sectional study, women with BC (N = 866) who had been diagnosed and followed up in the previous 10 years were recruited from the outpatient clinic of 4 general hospitals and one cancer association in China between August 2018 and October 2019. Lymphedema status was determined using the Norman telephone questionnaire as the patient-reported occurrence of hand/lower arm/upper arm swelling. Multiple logistic regression was used to identify risk factors for lymphedema.

RESULTS

The median time from BC diagnosis was 4.0 years (interquartile range, 2.0-5.0 years). 81.4% of the patients had undergone mastectomy. The prevalence of arm lymphedema among BC survivors was 49.0%. Age ≥50 years, monthly income <3000 RMB, modified radical mastectomy, postsurgical wound infection, chemotherapy, and radiotherapy were associated with an increased risk of BC-related arm lymphedema, whereas exercise of the affected arm, engagement in active physical activity, and timely reporting of symptoms of infection to a physician decreased the risk (P < 0.05).

CONCLUSIONS

Arm lymphedema is a common complication for postoperative BC survivors within 10 years. It is essential to identify patients at risk of lymphedema based on demographic, clinical, and lifestyle factors and implement interventions targeting modifiable lifestyle behaviors-eg, active physical activity during the postoperative period.

Breast Cancer-Related Lymphedema: Magnetic Resonance Imaging Evidence of Sparing Centered Along the Cephalic Vein

BACKGROUND

 A distinct pattern of edema distribution is seen in breast cancer-related lymphedema. The area of edema sparing has not been characterized in relation to anatomy. Specifically, alternate lymphatic pathways are known to travel adjacent to the cephalic vein. Our study aims to define the location of edema sparing in the arm relative to the cephalic vein.

METHODS

 A retrospective review of patients who underwent magnetic resonance imaging (MRI) between March 2017 and September 2018 was performed. Variables including patient demographics, arm volumes, and MRI data were extracted. MRIs were reviewed to define the amount of sparing, or angle of sparing, and the deviation between the center of sparing and the cephalic vein, or angle of deviation.

RESULTS

 A total of 34 consecutive patients were included in the analysis. Five patients demonstrated circumferential edema (no sparing) and 29 patients demonstrated areas of edema sparing. Advanced age (69.7 vs. 57.6 years) and greater excess arm volume (40.4 vs. 20.8%) correlated with having circumferential edema without sparing (p = 0.003). In 29 patients with areas of edema sparing, the upper arm demonstrated the greatest angle of sparing (183.2 degrees) and the narrowest in the forearm (99.9 degrees; p = 0.0032). The mean angle of deviation to the cephalic vein measured 3.2, -0.1, and -5.2 degrees at the upper arm, elbow, and forearm, respectively.

CONCLUSION

 Our study found that the area of edema sparing, when present, is centered around the cephalic vein. This may be explained by the presence of the Mascagni-Sappey (M-S) pathway as it is located alongside the cephalic vein. Our findings represent a key springboard for additional research to better elucidate any trends between the presence of the M-S pathway, areas of sparing, and severity of lymphedema.

Periclavicular Lymph Node Activation Maintains the Lymphatic Circulation of Upper Extremity Following Breast Cancer Surgery with Axillary Lymph Node Dissection

Backgrounds: Axillary lymph node dissection (ALND) can cause breast cancer-related lymphedema (BCRL). However, ALND does not always produce lymphedema to the breast cancer survivors. Therefore, we aimed to investigate the correlation between the finding of lymphoscintigraphy and lymphedema in patients undergoing breast cancer surgery with ALND. Methods and Results: Patients with BCRL (n = 73, mean age: 53.92 ± 11.13 years) after full ALND (levels I, II, and III) were retrospectively included in this study. All patients underwent lymphoscintigraphy and according to the findings of the imaging, patients were divided into three groups: negative group, periclavicular lymph nodes (P-LN) activation, and axillary lymph nodes (A-LN) activation. According to the extent of radiation therapy, groups were classified as the following: no radiation group (None), breast radiation group (BI), and breast irradiation in addition to P-LN (BI+PC). The percentage difference in the upper extremities was used as the marker of severity of lymphedema. The subjects in the negative group, P-LN, and A-LN were 34 (46.6%), 33 (45.2%), and 6 (8.2%) patients, respectively. The findings of lymphangiography showed statistically significant relationship with the severity of lymphedema. The extent of radiation therapy did not have statistically significant relationship. Despite ALND, 53.4% patients had active L/N capable of removing the upper limb lymphatic fluids and 45.2% patients showed activation of collateral formation of lymphatic circulation after ALND. Conclusion: The collateral lymphatic formation was provoked after breast cancer operation with ALND, which decreased the severity of lymphedema in breast cancer survivors.

Features, Predictors, and Treatment of Breast Cancer-related Lymphedema

Purpose of review

Breast cancer-related lymphedema (BCRL) is a common sequelae among breast cancer survivors. This review provides updated information on recent studies to prevent, diagnose, and actively treat women with BCRL.

Recent findings

In total, 63 articles were identified from 2015 and 2020 that assessed incidence, risk factors, surveillance, measurement and definition, treatment, and awareness of BCRL. Depending on the approach and timing of assessment, BCRL incidence rates ranged from 9.1% to 39%. Modified radical mastectomy, number of positive lymph nodes, and postoperative complications were linked to BCRL risk, in addition to chemotherapy, radiation, axillary lymph node dissection, advanced cancer stage, and higher body mass index. Early detection showed favorable BCRL outcomes (e.g., severity, symptoms). Exercise, self-management, complete decongestive therapy, bandaging, and surgery had positive effects on BCRL outcomes.

Summary

Numerous gaps exist within BCRL literature, such as the value of self-reported surveillance options to identify BCRL early, measurement strategies, and definitions of BCRL. In terms of policies, efforts are needed to educate providers, patients, payers, and legislators about the need for consensus to reduce the burden of BCRL in women being treated for breast cancer.

Integrating Biological Advances Into the Clinical Management of Breast Cancer Related Lymphedema

Breast cancer-related lymphedema (BCRL) occurs in a significant number of breast cancer survivors as a consequence of the axillary lymphatics' impairment after therapy (mainly axillary surgery and irradiation). Despite the recent achievements in the clinical management of these patients, BCRL is often diagnosed at its occurrence. In most cases, it remains a progressive and irreversible condition, with dramatic consequences in terms of quality of life and on sanitary costs. There are still no validated pre-surgical strategies to identify individuals that harbor an increased risk of BCRL. However, clinical, therapeutic, and tumor-specific traits are recurrent in these patients. Over the past few years, many studies have unraveled the complexity of the molecular and transcriptional events leading to the lymphatic system ontogenesis. Additionally, molecular insights are coming from the study of the germline alterations involved at variable levels in BCRL models. Regrettably, there is a substantial lack of predictive biomarkers for BCRL, given that our knowledge of its molecular milieu remains extremely puzzled. The purposes of this review were (i) to outline the biology underpinning the ontogenesis of the lymphatic system; (ii) to assess the current state of knowledge of the molecular alterations that can be involved in BCRL pathogenesis and progression; (iii) to discuss the present and short-term future perspectives in biomarker-based patients' risk stratification; and (iv) to provide practical information that can be employed to improve the quality of life of these patients.

Lymphaticovenular anastomosis for breast cancer-related upper extremity lymphedema: a literature review

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.

Improving the quality of life of patients with breast cancer-related lymphoedema by lymphaticovenous anastomosis (LVA): study protocol of a multicentre randomised controlled trial

INTRODUCTION

Early breast cancer detection and advancements in treatment options have resulted in an increase of breast cancer survivors. An increasing number of women are living with the long-term effects of breast cancer treatment, making the quality of survivorship an increasingly important goal. Breast cancer-related lymphoedema (BCRL) is one of the most underestimated complications of breast cancer treatment with a reported incidence of 20%. A microsurgical technique called lymphaticovenous anastomosis (LVA) might be a promising treatment modality for patients with BCRL. The main objective is to assess whether LVA is more effective than the current standard therapy (conservative treatment) in terms of improvement in quality of life and weather it is cost-effective.

METHODS AND ANALYSIS

A multicentre, randomised controlled trial, carried out in two academic and two community hospitals in the Netherlands. The study population includes 120 women over the age of 18 who have undergone treatment for breast cancer including axillary treatment (sentinel lymph node biopsy or axillary lymph node dissection) and/or axillary radiotherapy, presenting with an early stage lymphoedema of the arm, viable lymphatic vessels and received at least 3 months conservative treatment. Sixty participants will undergo the LVA operation and the other sixty will continue their regular conservative treatment, both with a follow-up of 24 months. The primary outcome is the health-related quality of life. Secondary outcomes are societal costs, quality adjusted life years, cost-effectiveness ratio, discontinuation rate of conservative treatment and excess limb volume.

ETHICS AND DISSEMINATION

The study was approved by the Ethics Committee of Maastricht University Medical Center (METC) on 19 December 2018 (NL67059.068.18). The results of this study will be disseminated in presentations at academic conferences, publications in peer-reviewed journals and other news media.

TRIAL REGISTRATION NUMBER

NCT02790021; Pre-results.

Functional lymphatic reconstruction with the "Selected Lymph Node" technique guided by a SPECT-CT lymphoscintigraphy

BACKGROUND

A new technique named "Selected Lymph Node" ("SeLyN") was evaluated, aiming to identify the most functional groin lymph nodes (LNs) for an effective LN transplantation.

METHODS

Bilateral lower-limb SPECT-CT was performed in the upper-limb lymphedema patients, to select the most radioactive inguinal LN. Recorded data included demographics, stage, etiology of lymphedema, flap consistency in accordance to preoperative findings, flap size, number of LN, and harvesting time. Infection episodes per year and volume changes of the upper limbs were documented. Donor-site complications were recorded and lower-limb evaluation was performed through clinical examination, volume analysis, and lymphoscintigraphy.

RESULTS

A total of 41 patients underwent a "SeLyN" transfer technique. The mean flap size was 28.34 cm² containing a mean of 3.4 LNs. The mean time spent on flap harvest was 39 minutes. A mean 56.5% volume reduction (P < .001) and a mean 1.41 to 0.29 infection episodes per patient per year (P < .001) were recorded. Clinical evaluation and lymphography of the donor site advocated no major complications for a mean follow-up period of 42.5 months.

CONCLUSIONS

"SeLyN" is a safe and effective technique in selecting the most suitable LNs, minimizing the donor-site morbidity, and decreasing the overall operating time.

Interrater and Intrarater Reliability of Subcutaneous Echogenicity Grade and Subcutaneous Echo-Free Space Grade in Breast Cancer-Related Lymphedema

Background: Subcutaneous echogenicity grade (SEG) and subcutaneous echo-free space (SEFS) grade allow semiquantitation of nonspecific subcutaneous tissue inflammation and fluid accumulation in breast cancer-related lymphedema. However, inter- and intrarater reliability of SEG and SEFS is yet to be reported. The objective of this study is to assess inter-rater and intrarater reliability of SEG and SEFS in patients with breast cancer-related lymphedema. Methods and Results: Two physiatrists performed SEG and SEFS grade to determine inter-rater and intrarater reliability. Inter-rater reliability for SEG and SEFS was excellent (Kappa [K] = 0.836, weighted Kappa [K_w] = 0.85; K = 0.884, K_w = 0.92). K and K_w values of SEG and SEFS grading systems indicated excellent intrarater reliability (K = 0.81, K_w = 0.83; K = 0.798, K_w = 0.82). This trial is registered with Clinicaltrials.gov, under number NCT03559296. Conclusions: Based on the findings of this study, SEG and SEFS demonstrated acceptable reliability. SEG and SEFS appear to be reliable and useful grading systems for the assessment of breast cancer-related lymphedema.

Lymphovascular invasion and extranodal tumour extension are risk indicators of breast cancer related lymphoedema: an observational retrospective study with long-term follow-up

Background

Breast cancer related lymphoedema (BCRL) occurs in a substantial proportion of breast cancer survivors and is a major contributor to patients’ disability. Regrettably, there are no validated predictive biomarkers, diagnostic tools, and strong evidence-supported therapeutic strategies for BCRL. Here, we provide an integrative characterization of a large series of women with node-positive breast cancers and identify new bona fide predictors of BCRL occurrence.

Methods

Three hundred thirty-two cases of surgically-treated node-positive breast cancers were retrospectively collected (2–10.2 years of follow-up). Among them, 62 patients developed BCRL. To identify demographic and clinicopathologic features related to BCRL, Fisher’s exact test or Chi-squared test were carried out for categorical variables; the Wilcoxon rank-sum was employed for continuous variables. Factors associated with BCRL occurrence were assessed using a Cox proportional hazards regression model.

Results

En-bloc dissection of the axillary lymph nodes but not the type of breast surgery impacted on BCRL development. Most of BCRL patients had a Luminal A-like neoplasm. The median number of lymph nodes involved by metastatic deposits was significantly higher in BCRL compared to the control group (p = 0.04). Both peritumoral lymphovascular invasion (LVI) and extranodal extension (ENE) of the metastasis had a negative impact on BCRL-free survival (p = 0.01). Specifically, patients with LVI and left side localization harboured 4-fold higher risk of developing BCRL, while right axillary nodes metastases with ENE increased the probability of BCRL compared to ENE-negative patients.

Conclusions

Assessment of LVI and ENE should be integrated with clinical and surgical data to improve BCRL risk stratification.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4851-2) contains supplementary material, which is available to authorized users.

Associations Between Sentinel Lymph Node Biopsy and Complications for Patients with Ductal Carcinoma In Situ

Purpose

To examine the associations between sentinel lymph node biopsy (SLNB) and complications among older patients who underwent breast-conserving surgery (BCS) for ductal carcinoma in situ (DCIS).

Methods

We identified women from the Surveillance, Epidemiology, and End Results–Medicare dataset aged 67–94 years diagnosed during 1998–2011 with DCIS who underwent BCS as initial treatment. We assessed incidence of complications, including lymphedema, wound infection, seroma, or pain, within 9 months of diagnosis. We used Mahalanobis matching and generalized linear models to estimate the associations between SLNB and complications.

Results

Our sample consisted of 15,515 beneficiaries, 2409 (15.5%) of whom received SLNB. Overall, 16.8% of women who received SLNB had complications, compared with 11.3% of women who did not receive SLNB (p < 0.001). Use of SLNB was associated with subsequent mastectomy but not radiotherapy. Multivariate analyses of the matched sample showed that, compared with no SLNB, SLNB use was significantly associated with incidence of any complication [adjusted odds ratio (AOR) 1.39; 99% confidence interval (CI) 1.18–1.63], lymphedema (AOR 4.45; 99% CI 2.27–8.75), wound infection (AOR 1.24; 99% CI 1.00–1.54), seroma (AOR 1.40; 99% CI 1.03–1.91), and pain (AOR 1.31; 99% CI 1.04–1.65). Sensitivity analyses excluding patients who underwent mastectomy yielded qualitatively similar results regarding the associations between SLNB and complications.

Conclusions

Among older women with DCIS who received BCS, SLNB use was associated with higher risks of short-term complications. These findings support consensus guidelines recommending against SLNB for this population and provide empirical information for patients.

Electronic supplementary material

The online version of this article (10.1245/s10434-018-6410-0) contains supplementary material, which is available to authorized users.

Arm Volumetry Versus Upper Extremity Lymphedema Index: Validity of Upper Extremity Lymphedema Index for Body-Type Corrected Arm Volume Evaluation

BACKGROUND

Volumetry, measurement of extremity volume, is a commonly used method for upper extremity lymphedema (UEL) evaluation. However, comparison between different patients with different physiques is difficult with volumetry, because body-type difference greatly affects arm volume.

METHODS

Seventy arms of 35 participants who had no history of arm edema or breast cancer were evaluated. Arm volume was calculated using a summed truncated cone model, and UEL index was calculated using circumferences and body mass index (BMI). Examinees' BMI was classified into 3 groups, namely, low BMI (BMI, <20 kg/m), middle BMI (BMI, 20-25 kg/m), and high BMI (BMI, >25 kg/m). Arm volume and UEL index were compared with corresponding BMI groups.

RESULTS

Mean (SD) arm volume was 1090.9 (205.5) mL, and UEL index 96.9 (5.6). There were significant differences in arm volume between BMI groups [low BMI vs middle BMI vs high BMI, 945.2 (107.4) vs 1045.2 (87.5) vs 1443.1 (244.4) mL, P < 0.001]. There was no significant difference in UEL index between BMI groups [low BMI vs middle BMI vs high BMI, 97.2 (4.2) vs 96.6 (4.6) vs 96.7 (9.9), P > 0.5].

CONCLUSIONS

Arm volume significantly increased with increase of BMI, whereas UEL index stayed constant regardless of BMI. Upper extremity lymphedema index would allow better body-type corrected arm volume evaluation compared with arm volumetry.

Efficacy and safety of Wuling San for treatment of breast-cancer-related upper extremity lymphoedema: study protocol for a pilot trial

INTRODUCTION

Breast-cancer-related upper extremity lymphoedema (BCUL), a common complication of mastectomy, can cause physical discomfort, psychological distress, cosmetic defects, functional disability and chronic recurrent erysipelas in the affected arm(s). It is a challenge to physicians involved in the management of these patients. Wuling San, a classic prescription in Traditional Chinese Medicine used in treating oedema for thousands of years, is reported by many Chinese journals to perform well in BCUL. Therefore, the aim of this study is to verify its efficacy and evaluate its safety using rigorous methodological designs in patients with BCUL.

METHODS AND ANALYSIS

To verify the efficacy and assess the safety of Wuling San over a placebo, this double-blind, randomised, placebo-controlled, multicentre trial will be carried out in three hospitals. A total of 200 eligible patients with BCUL will be randomly allocated, in a ratio of 1:1, to either the experimental medicine group or the placebo group. The primary outcome measure will be the proportion of absolute reduced limb volume, as measured by perometry. The second outcome measure will be the number of participants with adverse events. The assessment will be carried out at the following time points: before enrolment (baseline) and 2, 4, 6 and 8 weeks after treatment.

ETHICS AND DISSEMINATION

This trial will be conducted in accordance with the Declaration of Helsinki and supervised by the institutional review board of the Fourth Affiliated Hospital of Guangxi Medical University (approval number PJK2016088). All patients will receive information about the trial in verbal and written forms and will give informed consent before enrolment. This trial will help to demonstrate whether Wuling San is effective in the treatment of patients with BCUL. The results will be published in peer-reviewed journals or disseminated through conference presentations.

TRIAL REGISTRATION NUMBER

NCT02726477; Pre-results.

American Cancer Society/American Society of Clinical Oncology Breast Cancer Survivorship Care Guideline

The purpose of the American Cancer Society/American Society of Clinical Oncology Breast Cancer Survivorship Care Guideline is to provide recommendations to assist primary care and other clinicians in the care of female adult survivors of breast cancer. A systematic review of the literature was conducted using PubMed through April 2015. A multidisciplinary expert workgroup with expertise in primary care, gynecology, surgical oncology, medical oncology, radiation oncology, and nursing was formed and tasked with drafting the Breast Cancer Survivorship Care Guideline. A total of 1,073 articles met inclusion criteria; and, after full text review, 237 were included as the evidence base. Patients should undergo regular surveillance for breast cancer recurrence, including evaluation with a cancer-related history and physical examination, and should be screened for new primary breast cancer. Data do not support performing routine laboratory tests or imaging tests in asymptomatic patients to evaluate for breast cancer recurrence. Primary care clinicians should counsel patients about the importance of maintaining a healthy lifestyle, monitor for post-treatment symptoms that can adversely affect quality of life, and monitor for adherence to endocrine therapy. Recommendations provided in this guideline are based on current evidence in the literature and expert consensus opinion. Most of the evidence is not sufficient to warrant a strong evidence-based recommendation. Recommendations on surveillance for breast cancer recurrence, screening for second primary cancers, assessment and management of physical and psychosocial long-term and late effects of breast cancer and its treatment, health promotion, and care coordination/practice implications are made.

This guideline was developed through a collaboration between the American Cancer Society and the American Society of Clinical Oncology and has been published jointly by invitation and consent in both CA: A Cancer Journal for Clinicians and Journal of Clinical Oncology. Copyright © 2015 American Cancer Society and American Society of Clinical Oncology. All rights reserved. No part of this document may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without written permission by the American Cancer Society or the American Society of Clinical Oncology.

American Cancer Society/American Society of Clinical Oncology Breast Cancer Survivorship Care Guideline

Answer questions and earn CME/CNE The purpose of the American Cancer Society/American Society of Clinical Oncology Breast Cancer Survivorship Care Guideline is to provide recommendations to assist primary care and other clinicians in the care of female adult survivors of breast cancer. A systematic review of the literature was conducted using PubMed through April 2015. A multidisciplinary expert workgroup with expertise in primary care, gynecology, surgical oncology, medical oncology, radiation oncology, and nursing was formed and tasked with drafting the Breast Cancer Survivorship Care Guideline. A total of 1073 articles met inclusion criteria; and, after full text review, 237 were included as the evidence base. Patients should undergo regular surveillance for breast cancer recurrence, including evaluation with a cancer-related history and physical examination, and should be screened for new primary breast cancer. Data do not support performing routine laboratory tests or imaging tests in asymptomatic patients to evaluate for breast cancer recurrence. Primary care clinicians should counsel patients about the importance of maintaining a healthy lifestyle, monitor for post-treatment symptoms that can adversely affect quality of life, and monitor for adherence to endocrine therapy. Recommendations provided in this guideline are based on current evidence in the literature and expert consensus opinion. Most of the evidence is not sufficient to warrant a strong evidence-based recommendation. Recommendations on surveillance for breast cancer recurrence, screening for second primary cancers, assessment and management of physical and psychosocial long-term and late effects of breast cancer and its treatment, health promotion, and care coordination/practice implications are made.

Impact of Ipsilateral Blood Draws, Injections, Blood Pressure Measurements, and Air Travel on the Risk of Lymphedema for Patients Treated for Breast Cancer

PURPOSE

The goal of this study was to investigate the association between blood draws, injections, blood pressure readings, trauma, cellulitis in the at-risk arm, and air travel and increases in arm volume in a cohort of patients treated for breast cancer and screened for lymphedema.

PATIENTS AND METHODS

Between 2005 and 2014, patients undergoing treatment of breast cancer at our institution were screened prospectively for lymphedema. Bilateral arm volume measurements were performed preoperatively and postoperatively using a Perometer. At each measurement, patients reported the number of blood draws, injections, blood pressure measurements, trauma to the at-risk arm(s), and number of flights taken since their last measurement. Arm volume was quantified using the relative volume change and weight-adjusted change formulas. Linear random effects models were used to assess the association between relative arm volume (as a continuous variable) and nontreatment risk factors, as well as clinical characteristics.

RESULTS

In 3,041 measurements, there was no significant association between relative volume change or weight-adjusted change increase and undergoing one or more blood draws (P = .62), injections (P = .77), number of flights (one or two [P = .77] and three or more [P = .91] v none), or duration of flights (1 to 12 hours [P = .43] and 12 hours or more [P = .54] v none). By multivariate analysis, factors significantly associated with increases in arm volume included body mass index ≥ 25 (P = .0236), axillary lymph node dissection (P < .001), regional lymph node irradiation (P = .0364), and cellulitis (P < .001).

CONCLUSION

This study suggests that although cellulitis increases risk of lymphedema, ipsilateral blood draws, injections, blood pressure readings, and air travel may not be associated with arm volume increases. The results may help to educate clinicians and patients on posttreatment risk, prevention, and management of lymphedema.