Lymphedema after treatment of breast cancer

Symptoms: Lymphedema

Lymphedema is one of the main late effects from breast cancer treatment affecting 3-60% of breast cancer survivors. Primarily occurring in the hand, arm, and/or affected breast, symptoms of lymphedema include swelling, pain, redness, restriction of arm/hand movement, tightness and feelings of fullness. These symptoms not only may limit physical functioning but also negatively affect quality of life, body image, social functioning, and financial status of breast cancer survivors with lymphedema. Unfortunately, there are no standardized methods for prevention, diagnosis, and treatment of breast cancer-related lymphedema. Despite its prevalence and lack of clinical guidelines, lymphedema is one of the most poorly understood, relatively underestimated, and least researched complications of cancer treatment. This chapter reviews the current problem of breast cancer-related lymphedema by investigating prevention and risk reduction strategies, diagnosis, and treatment. In addition, this chapter identifies future research opportunities focusing on prevention and risk reduction strategies, quality of life and physical function, surveillance, patient education, cost, diagnosis, and treatment. Challenges and recommendations for future research in these areas, particularly among underserved populations, are discussed.

Systemic analysis on risk factors for breast cancer related lymphedema

BACKGROUND

To evaluate risk factors for upper extremity lymphedema due to breast cancer surgery.

MATERIALS AND METHODS

Clinical studies published on PubMed, Ovid, EMbase, and Cochrane Library from January 1996 to December 2012 were selected.

RESULTS

Twenty-five studies were identified, including 12,104 patients. Six risk factors related to the incidence of lymphedema after breast cancer treatment were detected: axillary lymph node dissection (OR=3.73, 95%CI 1.16 to 11.96), postoperative complications (OR=2.64, 95%CI 1.10 to 6.30), hypertension (OR=1.83, 95%CI 1.38 to 2.42), high body mass index (OR=1.80, 95%CI 1.30 to 2.49), chemotherapy (OR=1.38, 95%CI 1.07 to 1.79) and radiotherapy (OR=1.35, 95%CI 1.10 to 1.66). We found significant protective factors for lymphedema: pathologic T classification (OR=0.57, 95%CI 0.36 to 0.91) and stage (OR=0.60, 95%CI 0.39 to 0.93), while some factors, like age, number of positive lymph nodes, number of lymph node dissection, demonstrated no obvious correlation.

CONCLUSIONS

Axillary lymph node dissection, postoperative complications, hypertension, body mass index, chemotherapy, radiotherapy are risk factors for lymphedema after breast cancer treatment. Attention should be paid to patients with risk factors to prevent the occurrence of lymphedema.

The effect of smoking and major vein resection on post-therapy lymphedema in soft tissue sarcomas treated with neoadjuvant radiation and limb-salvage surgery

BACKGROUND

Neoadjuvant therapy with radiation +/- chemotherapy is an accepted management for soft tissue sarcomas (STS). The incidence of post-therapy lymphedema is around 30%. The purpose of this study was to identify variables that predict for post-therapy lymphedema.

METHODS

From 2000 to 2010, 132 patients with STS were treated with neoadjuvant radiation +/- chemotherapy followed by resection. Patient variables and treatment outcomes were reviewed. Presence of lymphedema was determined by the treating physician. The Fisher exact test was used for univariate analysis and logistic regression was used for multivariate analysis.

RESULTS

Median follow-up was 3.1 years. Of the lower extremity STS, major veins were sacrificed in 34% of patients. Lymphedema occurred in 22.4% of patients. Smoking negatively predicted for lymphedema on univariate analysis (P=0.007), and sacrifice of a major vein was associated with an increased risk of lymphedema (P=0.02). On multivariate analysis, smoking (P=0.02, odds ratio 0.31) negatively predicted for and sacrifice of a major vein (P=0.03, odds ratio 2.7) positively predicted for lymphedema.

CONCLUSIONS

There may be an association between smoking and decrease post-therapy lymphedema. Also, patients who undergo resection of a major vein seem to be more prone to post-therapy lymphedema.

Impact of adjuvant taxane-based chemotherapy on development of breast cancer-related lymphedema: results from a large prospective cohort

Taxane-based chemotherapy for the treatment of breast cancer is associated with fluid retention in the extremities; however, its association with development of breast cancer-related lymphedema is unclear. We sought to determine if adjuvant taxane-based chemotherapy increased risk of lymphedema or mild swelling of the upper extremity. 1121 patients with unilateral breast cancer were prospectively screened for lymphedema with perometer measurements. Lymphedema was defined as a relative volume change (RVC) of ≥10 % from preoperative baseline. Mild swelling was defined as RVC 5- <10 %. Clinicopathologic characteristics were obtained via medical record review. Kaplan-Meier and Cox proportional hazard analyses were performed to determine lymphedema rates and risk factors. 29 % (324/1121) of patients were treated with adjuvant taxane-based chemotherapy. The 2-year cumulative incidence of lymphedema in the overall cohort was 5.27 %. By multivariate analysis, axillary lymph node dissection (ALND) (p < 0.0001), higher body mass index (p = 0.0007), and older age at surgery (p = 0.04) were significantly associated with increased risk of lymphedema; however, taxane chemotherapy was not significant when compared to no chemotherapy and non-taxane chemotherapy (HR 1.14, p = 0.62; HR 1.56, p = 0.40, respectively). Chemotherapy with docetaxel was significantly associated with mild swelling on multivariate analysis in comparison to both no chemotherapy and non-taxane chemotherapy groups (HR 1.63, p = 0.0098; HR 2.15, p = 0.02, respectively). Patients who receive taxane-based chemotherapy are not at an increased risk of lymphedema compared to patients receiving no chemotherapy or non-taxane adjuvant chemotherapy. Those treated with docetaxel may experience mild swelling, but this does not translate into subsequent lymphedema.

Bioluminescence-activated deep-tissue photodynamic therapy of cancer

Optical energy can trigger a variety of photochemical processes useful for therapies. Owing to the shallow penetration of light in tissues, however, the clinical applications of light-activated therapies have been limited. Bioluminescence resonant energy transfer (BRET) may provide a new way of inducing photochemical activation. Here, we show that efficient bioluminescence energy-induced photodynamic therapy (PDT) of macroscopic tumors and metastases in deep tissue. For monolayer cell culture in vitro incubated with Chlorin e6, BRET energy of about 1 nJ per cell generated as strong cytotoxicity as red laser light irradiation at 2.2 mW/cm² for 180 s. Regional delivery of bioluminescence agents via draining lymphatic vessels killed tumor cells spread to the sentinel and secondary lymph nodes, reduced distant metastases in the lung and improved animal survival. Our results show the promising potential of novel bioluminescence-activated PDT.

Prevention and management of lymphedema after breast cancer treatment

Lymphedema of the arm after breast cancer treatment continues to challenge clinicians worldwide. In this review, we examine the main modalities, both nonsurgical and surgical, to prevent and treat this as yet incurable condition.

Factors influencing response to lymphedema treatment in patients with breast cancer-related lymphedema

PURPOSE

In clinical practice, noticeable differences are seen in patient response to the treatment of breast cancer-related lymphedema. Although some factors influencing response to treatment are mentioned in the literature, there is no sufficient evidence and results are confusing. For this reason, our objective in this study is to identify predictive and response-related factors for response to treatment of breast cancer-related lymphedema.

METHODS

We analyzed data retrospectively from the files of patients with breast cancer-related lymphedema between 2006 and 2012. Patient demographics, clinical variables, and patient variables were recorded. Circumference measurements of lymphedema and healthy arms were recorded. We used a computer program (Limb Volumes Professional version 5.0) to transform these values to limb volumes in milliliters.

RESULTS

The average age of 331 patients was 54.4 ± 10.9. The average length of lymphedema treatment was 2.92 ± 1.3 weeks. A statistically significant positive correlation was found between postoperative weight gain and postoperative duration, number of chemotherapy (CT) cycles, duration of tamoxifen use, and duration of hormonal therapy (p < 0.05). There was a statistically significant negative correlation between posttreatment arm volume and activity level, postoperative duration, and postoperative weight gain (p < 0.05).

CONCLUSION

The treatment methods used for treating breast cancer had no effect on the response to treatment of lymphedema. Weight gain during the treatment of breast cancer is important for both the development of lymphedema and the response to treatment. When treating breast cancer-related lymphedema, the relationship between activity level and postoperative weight gain may provide us guidance in clinical practice.

Risk factors for self-reported arm lymphedema among female breast cancer survivors: a prospective cohort study

INTRODUCTION

Lymphedema is a potentially debilitating condition that occurs among breast cancer survivors. This study examines the incidence of self-reported lymphedema, timing of lymphedema onset, and associations between sociodemographic, clinical and lifestyle factors and lymphedema risk across racial-ethnic groups using data from a multicenter, multiethnic prospective cohort study of breast cancer survivors, the Health, Eating, Activity and Lifestyle Study.

METHODS

A total of 666 women diagnosed with breast cancer staged as in situ, localized or regional disease at ages 35 to 64 years were recruited through the Surveillance, Epidemiology, and End Results registries in New Mexico (non-Hispanic white and Hispanic white), Los Angeles County (black), and Western Washington (non-Hispanic white) and followed for a median of 10.2 years. We evaluated sociodemographic factors, breast cancer- and treatment-related factors, comorbidities, body mass index (BMI), hormonal factors, and lifestyle factors in relation to self-reported lymphedema by fitting Cox proportional hazards models, estimating hazard ratios (HR) and 95% confidence intervals (CI).

RESULTS

Over the follow-up period, 190 women (29%) reported lymphedema. The median time from breast cancer diagnosis to onset of lymphedema was 10.5 months (range: 0.5 to 134.9 months). Factors independently associated with lymphedema were total/modified radical mastectomy (versus partial/less than total mastectomy; HR = 1.37, 95% CI: 1.01 to 1.85), chemotherapy (versus no chemotherapy; HR = 1.48, 95% CI: 1.09 to 2.02), no lymph nodes removed (versus ≥10 lymph nodes removed; HR = 0.17, 95% CI: 0.08 to 0.33), pre-diagnostic BMI ≥30 kg/m2 (versus BMI <25 kg/m2; HR = 1.59, 95% CI: 1.09 to 2.31), and hypertension (versus no hypertension; HR = 1.49, 95% CI: 1.06 to 2.10). After adjusting for demographics and breast cancer- and treatment-related factors, no significant difference in lymphedema risk was observed across racial/ethnic groups. Analyses stratified by race/ethnicity showed that hypertension and chemotherapy were lymphedema risk factors only for black women.

CONCLUSIONS

Breast cancer patients who have undergone extensive surgery or extensive lymph node dissection, or who have a higher BMI should be closely monitored for detection and treatment of lymphedema. Further studies are needed to understand the roles of chemotherapy and hypertension in the development of lymphedema.

Contrast-enhanced magnetic resonance lymphography in the assessment of lower limb lymphoedema

Chronic lower limb lymphoedema is a debilitating condition that may occur as a primary disorder or secondary to other conditions. Satisfactory visualization of the lymphatic vessels to aid diagnosis and surgical planning has been problematic. Historically, direct lymphography was used to visualize lymphatic vessels, although the significant surgical risks involved led to this being largely abandoned as a technique. Technetium-99m lymphoscintigraphy has been the mainstay of diagnosis for over two decades, but is hampered by inherently poor temporal and spatial resolution and limited anatomical detail. Contrast-enhanced magnetic resonance lymphography (MRL) is a relatively new technique that shows early promise in the evaluation of chronic lymphoedema. This article provides the procedural technique for lower limb MRL at both 1.5 and 3 T, discusses pathophysiology and classifications of lymphoedema, provides an overview of relevant lower limb lymphatic anatomy using MRL imaging, compares the various techniques used in the diagnosis of lower limb lymphoedema, shows common pathological MRL imaging findings, and describes alternative uses of MRL. Utilization of this technique will allow more accurate diagnosis and classification of patients suffering from lymphoedema.

Lymphatic function is impaired following irradiation of a single lymph node

INTRODUCTION

Lymph nodes are often the target of radiotherapy procedures. Unfortunately, the impact of nodal irradiation on lymphatic function is uncertain. In this study, our aim was to quantify the impact of lymph node irradiation on lymph flow.

METHODS AND RESULTS

The popliteal node or the nodal excision site of rabbits was treated with four daily 8 Gy doses of radiation. A FITC-dextran tracer was infused into a prenodal popliteal lymphatic. The area under the tracer blood recovery curve (AUC) indicated lymphatic functionality and the inflow pressure versus flow rate relationship inferred resistance through the system. Fluoroscopic and histological examination provided supporting data. Radiation of intact nodes decreased lymph transport significantly at 1 week, 1 month, and 6 months post-treatment (AUCs of 207.9 ± 79.87, 191.6 ± 62.95, and 250.44 ± 46.45) in comparison to controls (667.32 ± 104.18). Surprisingly, this functional decline was similar to that detected with a combination of node removal and irradiation of the excision site. The pressure-flow relationships in all treatment groups were significantly different from controls. This may be due in part to fibrosis and the thickening of the nodal capsules and trabeculae observed at 1 and 6 months. Fluoroscopy and Evans blue dye studies revealed vigorous new lymphatic vessel growth and occasionally, vessels anastomosed with local veins.

CONCLUSIONS

Irradiation of the popliteal lymph node impaired lymph transport and increased the pressure required to maintain flow through the system. New vessel formation and the growth of lymph-venous anastomoses indicated the development of alternative drainage pathways as a compensatory response.

Frequency of Early-Stage Lymphedema and Risk Factors in Postoperative Patients with Breast Cancer

OBJECTIVE

Lymphedema is a chronic major complication that is seen frequently post-operatively and has negative effects on quality of life. In our study, determining the early-stage postoperative lymphedema frequency and specifying the risk factors in its development has been aimed.

MATERIALS AND METHODS

One hundred one cases that were operated on for breast cancer were evaluated regarding the 12-month control of their clinical specifications, histopathological specifications, and specifications related with the surgical intervention retrospectively. The data related to the parameters envisioned as risk factors were evaluated.

RESULTS

Lymphedema development was found in 7 (6.9%) out of 101 cases constituting the study group. No significant difference (p>0.05) in terms of lymphedema development was determined among age, body mass index (BMI), chemotherapy (CT), postoperative seroma or infection, mastectomy with the dominant arm, and breast-conserving surgery (BCS), which were evaluated as risk factors. There was a significance (p<0.05) between the other risk factors, which were axillary dissection (AD), number of positive lymph nodes (LN), radiotherapy (RT), the tumor size (T), and lymphedema existence. In every case in which lymphedema was determined, it was seen that there was axillary LN involvement and 15≤LN were ablated in the dissection (p<0.05).

CONCLUSION

It is seen that AD, RT applied to the breast cancer patients, and T are important risk factors in early-stage lymphedema development. No early-stage lymphedema development was determined in any of the patients to whom sentinel lymph node dissection (SLND) was applied.

Prognostic value of lymphoscintigraphy in patients with gynecological cancer-related lymphedema

BACKGROUND AND OBJECTIVES

We investigated the prognostic value of qualitative lymphoscintigraphy in gynecological cancer-related lymphedema, which is a common complication after treatment.

METHODS

All 152 patients underwent (99m) Tc tin-colloid lymphoscintigraphy before complex decongestive therapy (CDT). We analyzed the uptake patterns of the inguinal lymph nodes, main lymphatic vessel and collateral lymphatic vessels, as well as dermal back flow. We compared these lymphoscintigraphic findings and other clinical variables between good and poor therapeutic responders using Pearson's Chi-squared test, Fisher's exact test and multiple logistic regression analysis.

RESULTS

Eighty-nine patients (58.6%) had a poor therapeutic response to CDT. In univariate analysis, there were significant differences between good and poor responders in clinical stage (P < 0.001), therapy compliance (P < 0.001), main lymphatic vessel uptake pattern (P < 0.01), collateral lymphatic vessel uptake pattern (P < 0.01) and severity of dermal back flow (P < 0.001). After multivariate analysis, only severity of dermal back flow (P < 0.005), clinical stage (P < 0.05) and therapy compliance (P < 0.001) were found to be independent predictors of therapeutic response.

CONCLUSIONS

Lymphoscintigraphy may be useful to predict the outcome of patients with gynecological cancer-related lymphedema undergoing CDT along with clinical stage and compliance.

The effect of prospective monitoring and early physiotherapy intervention on arm morbidity following surgery for breast cancer: a pilot study

PURPOSE

Significant arm morbidity is reported following surgery for breast cancer, yet physiotherapy is not commonly part of usual care. This study compared the effect on arm morbidity after surgery for breast cancer of a clinical care pathway including preoperative education, prospective monitoring, and early physiotherapy (experimental group) to that of preoperative education alone (comparison group).

METHODS

A prospective quasi-experimental pretest-posttest, non-equivalent group design compared two clinical sites; Site A (n=41) received the experimental intervention, and Site B (n=31) received the comparison intervention. At baseline (preoperative) and 7 months postoperative, shoulder range of motion (ROM), upper-extremity (UE) strength, UE circumference, pain, UE function, and quality of life were assessed.

RESULTS

The experimental group maintained shoulder flexion ROM at 7 months, whereas the comparison group saw a decrease (mean 1° [SD 9°] vs. -6° [SD 15°], p=0.03). A lower incidence of arm morbidity and better quality of life were observed in the experimental group, but these findings were not statistically significant. Baseline characteristics and surgical approaches differed between the two sites, which may have had an impact on the findings.

CONCLUSION

Initial results are promising and support the feasibility of integrating a surveillance approach into follow-up care. This pilot study provides the foundation for a larger, more definitive trial.

Defining a threshold for intervention in breast cancer-related lymphedema: what level of arm volume increase predicts progression?

The purpose of this study is to evaluate arm volume measurements and clinico-pathologic characteristics of breast cancer patients to define a threshold for intervention in breast cancer-related lymphedema. We prospectively performed arm volume measurements on breast cancer patients using a Perometer. Arm measurements were performed pre- and post-operatively, and change in arm volume was quantified using a relative volume change (RVC) equation. Patient and treatment risk factors were evaluated. Cox proportional hazards models with time-dependent covariates for RVC were used to evaluate whether RVC elevations of ≥3 to <5 % or ≥5 to <10 % occurring ≤3 months or >3 months after surgery were associated with progression to ≥10 % RVC. 1,173 patients met eligibility criteria with a median of 27 months post-operative follow-up. The cumulative incidence of ≥10 % RVC at 24 months was 5.26 % (95 % CI 4.01-6.88 %). By multivariable analysis, a measurement of ≥5 to <10 % RVC occurring >3 months after surgery was significantly associated with an increased risk of progression to ≥10 % RVC (HR 2.97, p < 0.0001), but a measurement of ≥3 to <5 % RVC during the same time period was not statistically significantly associated (HR 1.55, p = 0.10). Other significant risk factors included a measurement ≤3 months after surgery with RVC of ≥3 to <5 % (p = 0.007), ≥5 to <10 % (p < 0.0001), or ≥10 % (p = 0.023), axillary lymph node dissection (ALND) (p < 0.0001), and higher BMI at diagnosis (p = 0.0028). Type of breast surgery, age, number of positive or number of lymph nodes removed, nodal radiation, chemotherapy, and hormonal therapy were not significant (p > 0.05). Breast cancer patients who experience a relative arm volume increase of ≥3 to <5 % occurring >3 months after surgery do not have a statistically significant increase in risk of progression to ≥10 %, a common lymphedema criterion. Our data support utilization of a ≥5 to <10 % threshold for close monitoring or intervention, warranting further assessment. Additional risk factors for progression to ≥10 % include ALND, higher BMI, and post-operative arm volume elevation.

Safety of salvaging impending flap congestion in breast reconstruction by venous supercharging of the cephalic vein

Autologous flap breast reconstruction is an established technique that carries a risk of vascular failure. We evaluated the safety of salvaging impending venous congestion by using the cephalic vein for supercharging autologous abdominal flaps. Our main outcome measures were flap survival, triggering or impairing lymphedema as measured by the physician or reported by the patient, and scar severity as measured by the Vancouver scar scale. We were able to save 100% of the flaps, but could not find any statistical association with or without increased lymphedema before and after the procedure. One patient reported that lymphedema worsened. The patients accepted the scars (mean Vancouver scar scale score, 5.7). In sum, using the cephalic vein to improve venous drainage of autologous breast reconstruction was safe and did not trigger or impair lymphedema, but scarring in the upper arm was unavoidable.

The new era of the lymphatic system: no longer secondary to the blood vascular system

The blood and lymphatic systems are the two major circulatory systems in our body. Although the blood system has been studied extensively, the lymphatic system has received much less scientific and medical attention because of its elusive morphology and mysterious pathophysiology. However, a series of landmark discoveries made in the past decade has begun to change the previous misconception of the lymphatic system to be secondary to the more essential blood vascular system. In this article, we review the current understanding of the development and pathology of the lymphatic system. We hope to convince readers that the lymphatic system is no less essential than the blood circulatory system for human health and well-being.

Incidence of unilateral arm lymphoedema after breast cancer: a systematic review and meta-analysis

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.

Reduced incidence of breast cancer-related lymphedema following mastectomy and breast reconstruction versus mastectomy alone

BACKGROUND

As breast cancer survivorship has increased, so has an awareness of the morbidities associated with its treatment. The incidence of breast cancer-related lymphedema has been reported to be 8 to 30 percent in all breast cancer survivors. To determine whether breast cancer reconstruction has an impact on the incidence of breast cancer-related lymphedema, the authors compared its incidence in patients who underwent mastectomy with reconstruction versus mastectomy alone.

METHODS

All patients who underwent mastectomy, with or without immediate breast reconstruction, between 2001 and 2006, were identified through a search of prospective institutional databases. To reduce variation caused by known predictive factors, the individuals were cross-matched for age, axillary intervention, and postoperative axillary irradiation. The incidence of lymphedema was based on the presence of arm edema that lasted more than 6 months and was documented clinically.

RESULTS

Of the 574 cross-matched patients included in the study, 78 (6.8 percent) developed lymphedema (21 with reconstructed breasts and 57 with unreconstructed breasts). Patients who did not undergo reconstruction were significantly more likely to develop breast cancer-related lymphedema (9.9 percent versus 3.7 percent; p < 0.001). Postoperative axillary radiation therapy (p < 0.001), one or more positive lymph nodes (p = 0.010), and body mass index of 25 or greater (p = 0.021) were also associated with an increased incidence of lymphedema. Reconstruction patients developed lymphedema significantly later than nonreconstruction patients (p < 0.001).

CONCLUSION

Patients who undergo breast reconstruction have a lower incidence and a delay in onset of breast cancer-related lymphedema compared with patients who undergo mastectomy alone.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Reliability of frozen section in breast sentinel lymph node examination

OBJECTIVES

Sentinel lymph node (SLN) examination in breast carcinoma is crucial to spare patients unnecessary lymph node (LN) dissection. The specificity and accuracy of SLN examination by frozen section has been variable in many studies. This study aims to describe our experience in frozen section (FS) analysis of SLN.

METHODS

We have retrospectively analyzed data from 449 axillary SLN subjected to FS examination from 440 patients with breast cancer. All patients had free axillary LN clinically.

RESULTS

Out of 449 cases, no false positive cases were found on FS (specificity of 100 %). Twenty-six cases were false negative (6 interpretation-related reasons and 20 technical-related reasons). The overall sensitivity was 84 % with a total accuracy rate of 93 % and interpretation sensitivity of 96 %. Three cases were deferred. Twenty-two of the false negative cases were micrometastases, whereas 4 were macrometastases. The interpretation-related false negative cases were not related to the subtype of carcinoma (ductal vs. lobular). However, they were all of low nuclear grade.

CONCLUSION

These findings are similar to most published data. FS is a reliable method for evaluating SLN. The most common cause of false negative diagnosis is sampling error. More attention should be paid to low-grade tumors. Moreover, in FS analysis, we recommend to totally submit SLNs that are less than 5 mm in diameter, bisecting them if possible, and to serially section SLNs that are at least 5 mm at 2-mm intervals.

Would complex decongestive therapy reveal long term effect and lymphoscintigraphy predict the outcome of lower-limb lymphedema related to gynecologic cancer treatment?

OBJECTIVE

The aims of this study were to investigate the long-term effect of complex decongestive therapy (CDT) on lymphedema volume reduction, especially considering the proximal and distal parts of the leg, and to evaluate the utility of pre-therapy lymphoscintigraphy in predicting the response to CDT in patients with lower-limb lymphedema after surgery for gynecologic cancer.

METHODS

Medical records of 158 patients with secondary lymphedema of unilateral leg after surgery for gynecological cancer were reviewed retrospectively. They were treated with two weeks of CDT along with self-administered home therapy and were followed up for 24 months. Whole, proximal and distal leg volume was serially measured by using an optoelectric volumeter prior to and immediately after therapy, and follow-up visits at months 3, 6, 12 and 24. Lymphoscintigraphy was performed prior to therapy.

RESULTS

The percent volume reduction was 22.1% in the whole leg, 30.9% in the distal leg and 18.4% in the proximal leg immediately after CDT. The volume reduction was maintained for 24 months, but the distal leg was significantly well maintained better than the proximal leg. Extremity radioisotope uptake ratio (EUR) among lymphoscintigraphic findings could predict the improvement of lymphedema volume in the distal, proximal and whole leg.

CONCLUSIONS

This study suggests that the long-term edema reducing effects of CDT are better maintained in the distal leg than in the proximal part, and initial lymphoscintigraphic quantitative finding may usefully predict the short and long-term response to CDT.

A systematic review of the effect of low-level laser therapy in the management of breast cancer-related lymphedema

PURPOSE

The purpose of this study was to review the effect of low-level laser therapy (LLLT) in the management of breast cancer-related lymphedema (BCRL).

METHODS

A systematic review of seven databases for clinical trials for LLLT in the management of BCRL published between 1990 and 2011 was performed.

RESULTS

A total of eight studies on 230 patients were found. The methodological qualities of the selected studies were assessed with the Physiotherapy Evidence Database scale, and the studies were categorized according to Sackett's levels of evidence. Five studies were graded at evidence level II. Two studies were graded at evidence level III, and the remaining study was graded at evidence level V.

CONCLUSIONS

There is moderate to strong evidence for the effectiveness of LLLT for the management of BCRL from five small studies of acceptable methodological quality. A dose of 1-2 J/cm(2) per point applied to several points covering the fibrotic area can reduce limb volume following BCRL. Further well-designed, large-scale studies are required to determine more precisely how effective LLLT may be in BCRL.

The impact of immediate breast reconstruction on post-mastectomy lymphedema in patients undergoing modified radical mastectomy

The aim of this study was to assess the impact of immediate breast reconstruction (IBR) with autologous tissue on the development of post-mastectomy lymphedema in patients undergoing modified radical mastectomy (MRM). A retrospective chart review was performed for early-stage breast cancer patients who underwent MRM between January 2001 and December 2009. Patients were categorized into two groups based on whether or not they underwent IBR. The incidence of lymphedema was assessed and compared. A total of 712 patients underwent MRM, which included 117 patients undergoing IRB. There were no significant differences between two groups except for a lower body mass index in the reconstruction group. Comparing the incidence of lymphedema using multivariate logistic regression analysis, the reconstruction group had a significantly lower incidence of lymphedema (p-value = 0.023). Breast cancer patients who underwent MRM with IBR had a significantly lower incidence of lymphedema than those in the non-reconstruction group.

Improvement of upper extremity lymphedema after delayed breast reconstruction with an extended latissimus dorsi myocutaneous flap

Lymphedema is a common complication after mastectomy in breast cancer patients. Many treatment options are available, but no treatment results in a complete cure. We report a case of lymphedema that occurred after modified radical mastectomy in a breast cancer patient who showed objective improvement after delayed breast reconstruction with an latissimus dorsi myocutaneous flap. A 41-year-old female patient with left breast cancer had undergone modified radical mastectomy with axillary lymph node dissection and postoperative radiotherapy 12 years previously. Four years after surgery, lymphedema developed and increased in aggravation despite conservative treatment. Eight years after the first operation, the patient underwent delayed breast reconstruction using the extended latissimus dorsi myocutaneous flap method. After reconstruction, the patient's lymphedema symptoms showed dramatic improvement by subjective measures including tissue softness and feeling of lightness, and by objective measures of about 7 mL per a week, resulting in near normal ranges of volume. At a postoperative follow-up after 3 years, no recurrence was observed. Delayed breast reconstruction with extended latissimus dorsi myocutaneous flaps may be helpful to patients with lymphedema after mastectomy. This may be a good option for patients who are worried about the possibility of the occurrence or aggravation of secondary lymphedema.

Five-year follow-up of treatment outcomes in patients with early-stage breast cancer and clinically negative axillary nodes treated with no lymph node dissection or axillary clearance

BACKGROUND

Sentinel lymph node biopsy has steadily replaced axillary lymph node dissection (ALND) for staging clinically node-negative breast cancer. However, ALND remains standard management of the axilla when a tumor-positive sentinel lymph node is identified.

METHODS

We identified 460 patients with breast cancer (clinically T1/T2N0M0) from the database for 1999-2004. Patient age ranged from 26 to 81 (median 50) years. Patients who underwent mastectomy or breast-conserving surgery with or without ALND were compared for regional recurrence, disease-free survival, and overall survival.

RESULTS

Patients with ALND (n = 308) were compared with the no ALND group (n = 152). Five-year overall survival and disease-free survival were not significantly different between the two groups, while there was a significant difference between them for regional recurrence. Of the 152 patients who did not undergo axillary dissection, four developed ipsilateral axillary disease, most of whom were rescued by delayed axillary dissection. Further, the criterion for identifying lymphedema was used, ie, a 2 cm circumferential change at any measured location. As a result, the incidence of lymphedema in the ALND group was 12.7%, while it was not seen in the non ALND group.

CONCLUSION

There is a possibility that ALND may be omitted for cT1/T2N0M0 breast cancer through a combination of hormone therapy and adjuvant chemotherapy.

Risk factors for lymphedema in breast cancer survivors, the Iowa Women's Health Study

Risk factors for lymphedema and related arm symptoms in breast cancer (BC) survivors have not been examined using a large prospective population-based cohort. The Iowa Women's Health Study (IWHS) collected self-reported data for diagnosed lymphedema in 2004, and data for cancer diagnosis, treatment, behavioral and health characteristics between 1986 and 2003. We studied 1,287 women, aged 55-69 at baseline, who developed unilateral BC: n = 104 (8%) with diagnosed lymphedema, n = 475 (37%) with arm symptoms but without diagnosed lymphedema, and n = 708 without lymphedema. Age- and multivariate-adjusted logistic regression models examined risk factors for lymphedema and related arm symptoms (OR [95% confidence interval]). The mean time between BC and the 2004 survey was 8.1 ± 5.0 (mean ± SD) years. After multivariate adjustment, the following cancer characteristics were positively associated with lymphedema: tumor stage (regional vs. in situ: 3.92 [1.61-9.54]), number of excised nodes (highest vs. lowest quintile: 3.52 [1.32-9.34], P (trend) = 0.003), tumor-positive nodes (yes vs. no 2.12 [1.19, 3.79]), and adjuvant chemotherapy (yes vs. no: 3.05 [1.75-5.30]). Several health characteristics were positively associated with lymphedema: baseline body mass index (highest vs. lowest tertile: 3.24 [1.70-6.21]), waist and hip circumference, and general health (fair/poor vs. excellent: 3.44 [1.30-9.06]). Positive associations with arm symptoms were number of excised nodes (highest vs. lowest quintile: 2.38 [1.41-4.03], P (trend) = 0.007), axillary radiation (yes vs. no: 1.72 [1.15-2.57]), and baseline general health (fair/poor vs. excellent: 4.27 [2.60-7.00]). In the IWHS, obesity, poorer general health, and markers of more advanced cancer were risk factors for lymphedema and related arm symptoms in BC survivors.

Reviewing the Benefits of Physical Activity During Cancer Survivorship

Increasing physical activity is a possible strategy for the prevention and/or treatment of many physical and mental health conditions that are experienced among cancer survivors. Although engaging in physical activity is safe, feasible, and effective for cancer survivors, few are sufficiently active to obtain health benefits. This review summarizes findings from published research studies and review articles to highlight the benefits of physical activity for cancer survivors. For the purpose of this review, a cancer survivor is defined as an individual who has been diagnosed with cancer and who has completed all systemic or primary treatments. This review includes evidence from a wide range of sources to help provide a holistic summary of both quantitative and qualitative findings on the benefits of physical activity for cancer survivors. The benefits are presented within survival, biological/physiological, psychological, and social themes using a using a broad quality of life model. The evidence suggests physical activity is associated with reduced rates of mortality, improved immune function, improved health-related quality of life, decreased fatigue, improved fitness, maintenance of healthy weight and bone density, improved physical and psychological indicators of well-being, and that physical activity programs can foster social support and feelings of connectedness. This review establishes that physical activity may reduce the various adverse side effects associated with cancer treatments and improve cancer survivors’ physical, psychological and social quality of life facets. Encouraging physical activity is the first step in helping cancer survivors experience long-term health and well-being.

Role of intra-operative touch imprint cytology in the treatment of breast cancer

OBJECTIVES

A prospective study was carried out to evaluate the role of intra-operative touch imprint cytology (TIC) in the assessment of sentinel lymph node (SLN) involvement for staging and treatment of early-stage, clinically node-negative breast carcinoma.

METHODS

Forty-five patients with early-stage, clinically node-negative breast cancer underwent a SLN biopsy with intra-operative TIC. The SLN was bisected if its width was less than 4 mm or sliced every 2 mm if it was more than 4 mm. The imprint specimens were stained with haematoxylin and eosin (H&E). Rapid immunochemistry (IH) was performed in case of equivocal cytological result. Permanent sections were evaluated with H&E and IH staining. The results of TIC were compared to histopathological results.

RESULTS

The sensitivity, specificity and overall accuracy of TIC on a node basis were 65.5%, 96.3%, 85.5%, respectively. When calculated according to the size of SLN metastasis, the sensitivity of TIC for overt metastasis was 84.6%, while it was 62.5% for micrometastasis and 37.5% for sub-micrometastasis. The mean size of nodal metastasis was 5.08 mm and 1.25 mm for true positive and false negative results, respectively (P = 0.0236). Because of intra-operative TIC, 76.5% of the patients who needed further axillary lymph node dissection (ALND) could undergo this during the same operating time.

CONCLUSIONS

TIC is a rapid and reliable method for the intra-operative assessment of metastatic sentinel node involvement in patients with early-stage, clinically node-negative breast carcinoma. Despite a low sensitivity comparable to frozen section (FS) in detecting micro- and sub-micrometastases, the technique offers the advantage of full tissue preservation for subsequent histological analysis.

Study of incidence of lymphedema in Indian patients undergoing axillary dissection for breast cancer

Lymphedema of the upper extremity, in addition to being unsightly, can be painful, can limit the arm movements, increases the risk of infection and is psychologically distressing, serving as a constant reminder of cancer. 1. To ascertain the incidence of lymphedema in a hospital based population (in patients undergoing axillary dissection for breast cancer. 2. To determine the clinico-epidemilogical factors associated with the occurrence of lymphedema in these patients. For all patients undergoing axillary dissection, arm measurements were taken in the pre-& post-operative period from at least 3 sites; one in the arm, forearm and wrist (points fixed in reference to fixed bony landmarks). Patients included in this study were followed up for at least 12 months. Circumference difference of more than 5% was taken as mild lymphedema; more than 10% as moderate lymphedema and more than 15% as severe lymphedema. Data was analyzed using SPSS 11.0 statistical software. Of the 231 patients in this study mean age was 51.2 years, majority were housewives (71.9%) and postmenopausal (58.5%). Modified radical mastectomy (MRM), was performed on 203 (87.9%) patients. 57.2% patients had positive lymph nodes. The mean number of positive nodes was 6.52. Majority of the patients received chemo and radio therapy. Overall incidence of lymphedema was 41.1%. The definition of 5-10% increase as mild lymphedema may be a bit severe as in most patients with this increase, lymphedema is not clinically apparent. The incidence of moderate and severe lymphedema in our series is only 7.4%. The incidence of clinically significant lymphedema (moderate to severe lymphedema & symptomatic mild lymphedema) was 16.8%. Only axillary irradiation and pathological nodal status (pN3) emerged as significant risk factors for lymphedema development on multivariate analysis. Lymphedema once established is difficult to treat. Combination of axillary dissection with radiation and more nodal positivity seems to predispose to lymphedema. Prevention by means of sentinel node biopsy in early cases, good surgical technique, arm care post surgery, exercises and massage therapy may help reducing the incidence and/or severity.

Assessment of volume measurement of breast cancer-related lymphedema by three methods: circumference measurement, water displacement, and dual energy X-ray absorptiometry

BACKGROUND

Following treatment for breast cancer 12%-60% develop breast cancer-related lymphedema (BCRL). There are several ways of assessing BCRL. Circumference measurement (CM) and water displacement (WD) for volume measurements (VM) are frequently used methods in practice and research, respectively. The aim of this study was to evaluate CM and WD for VM of the BCRL arm and the contralateral arm, comparing the results with regional dual energy X-ray absorptiometry (DXA).

METHODS AND RESULTS

Twenty-four women with unilateral BCRL were included in the study. Blinded duplicate VM were obtained from both arms using the three methods mentioned above. CM and DXA were performed by two observers. WD was performed by a group of observers. Mean differences (d) in duplicated volumes, limits of agreement (LOA), and 95% confidence intervals (CI) were calculated for each method. The repeatability expressed as d (95% CI) between the duplicated VM of the BCRL arm and the contralateral arm was for DXA 3 ml (-6-11) and 3 ml (1-7), respectively. For CM and WD, the d (95% CI) of the BCRL arm were 107 ml (86-127) and 26 ml (-26-79), respectively and in the contralateral arm 100 ml (78-122) and -6 ml (-29-17), respectively.

CONCLUSIONS

DXA is superior in repeatability when compared to CM and WD for VM, especially for the BCRL arm but also the contralateral arm.

Avaliação dos fatores de risco no linfedema pós-tratamento de câncer de mama

A principal complicação tardia no pós-operatório de câncer de mama é o desenvolvimento do linfedema, uma doença crônica, progressiva, geralmente incurável. O aumento do volume do membro pode desfigurar a imagem corporal, assim como aumentar a morbidade física e psicológica da paciente, além de promover significativo prejuízo para as funções. O presente estudo foi desenvolvido por meio de uma revisão sistemática a partir do cruzamento aleatório das palavras-chave: "linfedema", "compensações linfáticas", "sistema linfático", "dissecção axilar", "fatores de risco" e "câncer de mama". Foram selecionados 18 artigos entre os anos de 1979 e 2009, nos quais foram encontrados como principais fatores de risco para o desenvolvimento do linfedema a radioterapia, radioterapia axilar, infecção, dissecção axilar seguida de radioterapia, obesidade, número de linfonodos retirados e comprometidos e agressividade da cirurgia. As formas de compensação linfática após a dissecção axilar, como as anastomoses linfo-linfáticas, podem ser prejudicadas pela formação cicatricial, seroma pós-operatório, radioterapia e exercícios inadequados para reabilitação de ombro no câncer de mama.

Lymphedema following cancer therapy in Slovenia: a frequently overlooked condition?

Introduction

Secondary lymphedema following cancer therapy is a frequent, often painful, quality of life disturbing condition, reducing the patients’ mobility and predisposing them to complications, e.g. infections and malignancies. The critical aspect of lymphedema therapy is to start as soon as possible to prevent the irreversible tissue damage.

Patients and methods

We performed a retrospective study of patients with lymphedema, treated at the Department of Dermatovenereology, University Medical Center Ljubljana, from January 2002 to June 2010. The patients’ demographic and medical data were collected, including type of cancer, type and stage of lymphedema, and time to first therapy of lymphedema. The number of referred patients with lymphedema following the therapy of melanoma, breast cancer, and uterine/cervical cancer, was compared to the number of patients expected to experience lymphedema following cancer therapy, calculated from the incidence reported in the literature.

Results

In the period of 8.5 years, 543 patients (432 females, 112 males) with lymphedema were treated. The results show that probably many Slovenian patients with secondary lymphedema following cancer therapy remain unrecognized and untreated or undertreated. In the majority of our patients, the management of lymphedema was delayed; on average, the patients first received therapy for lymphedema 3.6 years after the first signs of lymphedema.

Conclusions

To avoid a delay in diagnosis and therapy, and the complications of lymphedema following cancer therapy, the physician should actively look for signs or symptoms of lymphedema during the follow-up period, and promptly manage or refer the patients developing problems.

[Secondary limb lymphedema]

Lymphedema is related to congenital lymphatic abnormality (primary forms) or acquired (secondary forms) after lesions of lymphatic system. Upper to limb secondary lymphedema after breast cancer treatment is the most frequent in France. The first worldwide cause is lymphatic filariosis. Secondary lymphedema is related to adverse effects after cancer treatment including surgery with lymph nodes excision associated with radiotherapy: breast, melanoma for upper limb, cervical, uterine, prostate, bladder cancer, melanoma for lower limb. At lymphedema onset, deep venous thrombosis and recurrent cancer should be investigated. Rare causes of lymphedema are also reported: rheumatic diseases (rheumatoid arthritis), Kaposi sarcoma, retroperitoneal fibrosis, immunosuppressive agent (sirolimus).

Balancing lymphedema risk: exercise versus deconditioning for breast cancer survivors

Lymphedema, a common and feared negative effect of breast cancer treatment, is generally described by arm swelling and dysfunction. Risk averse clinical recommendations guided survivors to avoid the use of the affected arm. This may lead to deconditioning and, ironically, the very outcome women seek to avoid. Recently published studies run counter to these guidelines.

Effectiveness of early physiotherapy to prevent lymphoedema after surgery for breast cancer: randomised, single blinded, clinical trial

OBJECTIVE

To determine the effectiveness of early physiotherapy in reducing the risk of secondary lymphoedema after surgery for breast cancer.

DESIGN

Randomised, single blinded, clinical trial.

SETTING

University hospital in Alcalá de Henares, Madrid, Spain.

PARTICIPANTS

120 women who had breast surgery involving dissection of axillary lymph nodes between May 2005 and June 2007.

INTERVENTION

The early physiotherapy group was treated by a physiotherapist with a physiotherapy programme including manual lymph drainage, massage of scar tissue, and progressive active and action assisted shoulder exercises. This group also received an educational strategy. The control group received the educational strategy only.

MAIN OUTCOME MEASURE

Incidence of clinically significant secondary lymphoedema (>2 cm increase in arm circumference measured at two adjacent points compared with the non-affected arm).

RESULTS

116 women completed the one year follow-up. Of these, 18 developed secondary lymphoedema (16%): 14 in the control group (25%) and four in the intervention group (7%). The difference was significant (P=0.01); risk ratio 0.28 (95% confidence interval 0.10 to 0.79). A survival analysis showed a significant difference, with secondary lymphoedema being diagnosed four times earlier in the control group than in the intervention group (intervention/control, hazard ratio 0.26, 95% confidence interval 0.09 to 0.79).

CONCLUSION

Early physiotherapy could be an effective intervention in the prevention of secondary lymphoedema in women for at least one year after surgery for breast cancer involving dissection of axillary lymph nodes.

TRIAL REGISTRATION

Current controlled trials ISRCTN95870846.

Older breast cancer survivors: factors associated with self-reported symptoms of persistent lymphedema over 7 years of follow-up

Lymphedema of the arm is a common complication of breast cancer with symptoms that can persist over long periods of time. For older women (over 50% of breast cancer cases) it means living with the potential for long-term complications of persistent lymphedema in conjunction with the common diseases and disabilities of aging over survivorship. We identified women > or =65 years diagnosed with primary stage I-IIIA breast cancer. Data were collected over 7 years of follow-up from consenting patients' medical records and telephone interviews. Data collected included self-reported symptoms of persistent lymphedema, breast cancer characteristics, and selected sociodemographic and health-related characteristics. The overall prevalence of symptoms of persistent lymphedema was 36% over 7 years of follow-up. Having stage II or III (OR = 1.77, 95% CI: 1.07-2.93) breast cancer and having a BMI >30 (OR = 3.04, 95% CI: 1.69-5.45) were statistically significantly predictive of symptoms of persistent lymphedema. Women > or =80 years were less likely to report symptoms of persistent lymphedema when compared to younger women (OR = 0.44, 95% CI: 0.18-0.95). Women with symptoms of persistent lymphedema consistently reported worse general mental health and physical function. Symptoms of persistent lymphedema were common in this population of older breast cancer survivors and had a noticeable effect on both physical function and general mental health. Our findings provide evidence of the impact of symptoms of persistent lymphedema on the quality of survivorship of older women. Clinical and research efforts focused on risk factors for symptoms of persistent lymphedema in older breast cancer survivors may lead to preventative and therapeutic measures that help maintain their health and well-being over increasing periods of survivorship.