An evaluation of the etiological factors of lymphedema following radical mastectomy; an analysis of 1,007 cases

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) may reduce the risk of developing cancer-related lymphedema following axillary lymph node dissection (ALND)

Purpose

Patients undergoing axillary lymph node dissection (ALND) for breast cancer face a high risk of lymphedema, further increased by high body mass index (BMI) and insulin resistance. GLP-1 receptor agonists (GLP-1RAs) have the potential to reduce these risk factors, but their role in lymphedema has never been investigated. The purpose of this study was to determine if GLP-RAs can reduce the risk of lymphedema in patients undergoing ALND.

Methods

All patients who underwent ALND at a tertiary cancer center between 2010 and 2023 were reviewed. Patients with less than 2 years of follow-up from the time of ALND were excluded. Race, BMI, radiation, chemotherapy history, pre-existing diagnosis of diabetes, lymphedema development after ALND, and the use of GLP-1RAs were analyzed. Multivariate logistic regression analysis was performed to assess if there was a significant reduction in the risk of developing lymphedema after ALND. A sub-group analysis of non-diabetic patients was also performed.

Results

3,830 patients who underwent ALND were included, 76 of which were treated with. GLP-1 RAs. The incidence of lymphedema in the GLP-1 RA cohort was 6.6% (5 patients). Compared to 28.5% (1,071 patients) in the non-GLP-1 RA cohort. On multivariate regression analysis, patients who were treated with GLP-1 RA were 86% less likely to develop lymphedema compared to the non-GLP-1 RA cohort (OR 0.14, 95% CI 0.04-0.32, p < 0.0001). A BMI of 25 kg/m 2 or greater was a statistically significant risk factor for developing lymphedema with an odds ratio of 1.34 (95% CI 1.16-1.56, p < 0.0001). Diabetes was associated with lymphedema development that closely approached statistical significance (OR 1.32, 95% CI 0.97-1.78, p = 0.06). A subgroup analysis solely on non-diabetic patients showed similar results. The odds of developing lymphedema were 84% lower for patients without diabetes treated with GLP1-RAs compared to those who did not receive GLP-1 RAs (OR 0.16, 95% CI 0.05-0.40, p < 0.0001).

Conclusion

GLP1-RAs appear to significantly reduce the risk of lymphedema in patientsundergoing ALND. The mechanism of action may be multifactorial and not limited to weight reduction and insulin resistance. Future prospective analysis is warranted to clarify the role of GLP-1RAs in reducing lymphedema risk.

The Impact of Obesity on Success of Immediate Lymphatic Reconstruction for Prevention of Breast Cancer-Related Lymphedema

BACKGROUND

Breast cancer-related lymphedema (BRCL) is a potential sequela of high-risk breast cancer treatment. Preventive treatment with immediate lymphatic reconstruction (ILR) at the time of axillary lymph node dissection (ALND) has emerged as the standard of care; however, there is relatively little known about factors that may contribute to procedural failure.

METHODS

A retrospectively maintained, institutional review board-approved study followed patients who underwent ILR at the time of ALND at our tertiary care center between May 2018 and May 2023. Patients who presented for at least one follow-up visit in our multidisciplinary lymphedema clinic met the criteria for inclusion. Patients who developed lymphedema despite ILR and potential contributing factors were further explored.

RESULTS

349 patients underwent ILR at our institution between May 2018 and May 2023. 341 of these patients have presented for follow-up in our multidisciplinary lymphedema clinic. 32 (9.4%) patients developed lymphedema despite ILR. This cohort was significantly more likely to be obese (56% vs 35%, P = 0.04). Multivariate logistic regression demonstrates increased odds of procedural failure in patients with a body mass index (BMI) ≥30 kg/m2 (odds ratio 2.6 [1.2-5.5], P = 0.01).

CONCLUSION

These data comment upon our institutions outcomes following ILR. Patients who develop lymphedema despite ILR tend to have a higher BMI, with a significantly increased risk in patients with a BMI of 30 or greater. Consideration of these data is critical for preprocedural counseling and may support a BMI cutoff when considering candidacy for ILR going forward, as well as when optimizing failures for secondary lymphedema procedures.

Lymphatic Vessel Network Structure and Physiology

The lymphatic system is comprised of a network of vessels interrelated with lymphoid tissue, which has the holistic function to maintain the local physiologic environment for every cell in all tissues of the body. The lymphatic system maintains extracellular fluid homeostasis favorable for optimal tissue function, removing substances that arise due to metabolism or cell death, and optimizing immunity against bacteria, viruses, parasites, and other antigens. This article provides a comprehensive review of important findings over the past century along with recent advances in the understanding of the anatomy and physiology of lymphatic vessels, including tissue/organ specificity, development, mechanisms of lymph formation and transport, lymphangiogenesis, and the roles of lymphatics in disease. © 2019 American Physiological Society. Compr Physiol 9:207-299, 2019.

Lymphatic Dysfunction, Leukotrienes, and Lymphedema

The lymphatic system is essential for the maintenance of tissue fluid homeostasis, gastrointestinal lipid absorption, and immune trafficking. Whereas lymphatic regeneration occurs physiologically in wound healing and tissue repair, pathological lymphangiogenesis has been implicated in a number of chronic diseases such as lymphedema, atherosclerosis, and cancer. Insight into the regulatory mechanisms of lymphangiogenesis and the manner in which uncontrolled inflammation promotes lymphatic dysfunction is urgently needed to guide the development of novel therapeutics: These would be designed to reverse lymphatic dysfunction, either primary or acquired. Recent investigation has demonstrated the mechanistic role of leukotriene B₄ (LTB₄) in the molecular pathogenesis of lymphedema. LTB₄, a product of the innate immune response, is a constituent of the eicosanoid inflammatory mediator family of molecules that promote both physiological and pathological inflammation. Here we provide an overview of lymphatic development, the pathophysiology of lymphedema, and the role of leukotrienes in lymphedema pathogenesis.

Lymphedema and obesity: is there a link?

Lymphedema is a chronic disorder that, in developed countries, occurs most commonly after lymph node dissection for cancer treatment. Although the pathophysiology of lymphedema is unknown, the disease is characterized histologically by fibrosis and abnormal adipose deposition. Clinical studies have provided evidence that obesity and postoperative weight gain are significant risk factors for the development of lymphedema. In fact, recent studies have shown that extreme obesity can result in markedly impaired lymphatic function and primary lymphedema. The aim of this Special Topic article is to review evidence linking obesity and lymphedema. In addition, the authors review recent studies that have analyzed the cellular mechanisms that may be responsible for this relationship, with a goal of highlighting areas of research that may have significant translational potential.

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.

Preventing lymphedema and morbidity with an omentum flap after ilioinguinal lymph node dissection

BACKGROUND

Pedicled omentoplasty has been advocated to prevent the formation of lymphocysts and lymphedema after pelvic lymph node dissection, We evaluated the possible benefit of a pediculated omentoplasty placed in the groin for preventing complications after ilioinguinal lymph node dissection.

METHODS

In this pilot study, we report a series of four women and three men with inguinal metastatic lymph nodes. Each was treated with a pediculated omentoplasty after groin dissection. We examined complications such as lymphedema, lymphorrhea, wound breakdown, skin necrosis, and lymphocysts.

RESULTS

Only one wound breakdown with skin necrosis was observed, and it healed satisfactorily in 10 days without exposing the femoral vessels. No lymphocele or infectious complications occurred, even though no antibiotic prophylaxis was used. Midthigh circumference increase ranged from 1.5 to 7 cm in four cases but remained asymptomatic. Furthermore, lymphedema of the lower limb decreased in the three remaining patients, who previously had an enlargement of the thigh. No evidence of peritoneal carcinomatosis was noted during the 4-month follow-up.

CONCLUSIONS

Pedicled omentoplasty seemed to facilitate the absorption or transport of lymph fluids and resulted in less lymphedema in the lower limb even after radiotherapy. Pedicled omentoplasty reduces both short-term and long-term postoperative complications without affecting treatment outcome and could even be considered as a safe and effective therapy for lymphedema of the lower extremity.

Lymphoedema: estimating the size of the problem

Lymphoedema is a problem frequently encountered by professionals working in palliative care. This article reviews the evidence on the magnitude of the problem of lymphoedema in the general population and provides evidence on specific high risk groups within it. Prevalence is a good indicator of the burden of disease for chronic problems such as lymphoedema, as it indicates the numbers of patients who require care. Incidence is indicative of changes in the causes of lymphoedema and the success of any prevention programmes. Both are important means of assessing the current level of need and the potential for the changing needs in managing this condition. Problems exist in all studies in relation to precise definitions of lymphoedema, inconsistent measures to assess differential diagnosis and poorly defined populations. While there is some evidence of high rates in relation to breast cancer therapy, the total burden of lymphoedema in the general population is largely unknown.

Increased risk of soft tissue sarcoma after radiotherapy in women with breast carcinoma

BACKGROUND

Numerous studies to date have suggested an association between radiation exposure and the development of soft tissue sarcoma. The current study was performed to quantify the risk of soft tissue sarcoma in the vicinity of previously irradiated anatomic regions in women with breast carcinoma.

METHODS

In this population-based, retrospective cohort study, 194,798 women who were diagnosed with invasive breast carcinoma (exclusive of those with distant metastasis) between 1973--1995 were identified, and subsequent soft tissue sarcoma cases utilizing the data from the Surveillance, Epidemiology, and End Results Program (SEER) were ascertained. Poisson regression analysis was used to calculate age standardized incidence ratios (SIR) and to model the influence of radiotherapy (RT) on the relative risk (RR) between the RT and non-RT cohorts.

RESULTS

A total of 54 women in the RT cohort and 81 women in the non-RT cohort subsequently developed soft tissue sarcoma. In the RT cohort, the SIR was 26.2 (95% confidence interval [95% CI], 16.5--41.4) for angiosarcoma and was 2.5 (95% CI, 1.8--3.5) for other sarcomas; in the non-RT cohort, the SIRs were 2.1 (95% CI, 1.0--4.4) and 1.3 (95% CI, 1.0--1.7), respectively. The RT cohort demonstrated a higher risk of developing both angiosarcoma (RR: 15.9; 95% CI, 6.6--38.1) and other sarcomas (RR: 2.2; 95% CI, 1.4--3.3) compared with the non-RT cohort, and the largest increase was observed in the chest wall/breast. The elevated RR was significant even within 5 years of RT, but it reached a maximum between 5--10 years.

CONCLUSIONS

The risk of soft tissue sarcoma, especially angiosarcoma, was elevated after RT in women with breast carcinoma.

Lymphoedema following surgery for breast cancer

BACKGROUND

Lymphoedema is a common complication of breast cancer treatment, affecting approximately a quarter of patients. Those affected can have an uncomfortable, unsightly and sometimes functionally impaired limb prone to episodes of superficial infection. The aetiology, pathophysiology and management of these patients is poorly understood.

METHODS

This is a systematic review of all published literature on lymphoedema following treatment for breast cancer, using the Medline and Cinahl databases with cross-referencing of major articles on the subject up to the end of 1999.

RESULTS AND CONCLUSION

The aetiology and pathophysiology of lymphoedema in patients with breast cancer appear to be multifactorial and are still not fully understood. Although conservative treatment techniques can be very successful in controlling symptoms, they do not afford a cure. The place of surgical and pharmacological therapy remains unclear. Improved understanding of the pathophysiology may assist in reducing the incidence of this condition, or help to identify those at greatest risk, in whom early initiation of conservative treatment measures may prove effective.

Prevalence and aetiology of lymphoedema after breast cancer treatment in southern Tasmania

BACKGROUND

Lymphoedema can be a devastating complication of surgical treatment for breast cancer. There is a lack of research on its prevalence in Australia which has hindered the development of measures to combat the condition. The aims of this study were to establish the prevalence and investigate the aetiology of upper limb lymphoedema in women treated for breast cancer in the years 1994-1996 in southern Tasmania.

METHODS

A standard volumetric water displacement technique was used to measure the arms of 201 women. A subjective assessment of swelling was also made by each patient. Factors analysed for statistical association with lymphoedema were: patient characteristics, type of treatment and tumour, and lymph node pathology.

RESULTS

The overall objective prevalence rate, regardless of treatment type, was 11%; whereas, the subjective rate was 23.4%. The objective prevalence for procedures involving axillary surgery was 14.2%. Significant statistical associations were found between arm size and body mass index at time of assessment (r = 0.15, P = 0.04); type of surgery (Chi-squared test = 11.06, P = 0.05); surgery to axilla (U = 2515.5, P = 0.002); tumour size (r = 0.17, P = 0.03); and tumour grade (Chi-squared test = 6.5 1, P = 0.04). No significant relationship was found between lymphoedema and axillary irradiation, number of lymph nodes removed, age or handedness of the patient.

CONCLUSIONS

Women receiving axillary dissection as part of their breast cancer treatment carry a significant risk of developing lymphoedema, regardless of the extent of surgery. The causative role of axillary irradiation was not supported. Future research should concentrate on less invasive alternatives to axillary dissection, such as sentinal lymph node biopsy.

Groin dissection

This review provides a brief history of groin dissection, including studies on anatomical considerations and technique. A groin dissection for complete ablation of the node-bearing areolar tissue in the inguinal and iliac regions and with negligible morbidity requires careful attention to the pathophysiology of cancer in lymphatics, pre- and postoperative care, and surgical technique, including coordinated use and general, plastic, vascular, and orthopedic surgical principles.

Soft tissue sarcoma after treatment for breast cancer--a Swedish population-based study

The aim was to quantify the risk of post-treatment sarcoma in breast cancer patients. All 122,991 women with a breast cancer from 1958 to 1992 in the Swedish Cancer Register were followed up for soft tissue sarcomas and 116 were found, giving a standardised incidence ratio of 1.9 (95% CI 1.5-2.2). The absolute risk was 1.3 per 10(4) person-years. The sarcomas were located in the breast region or on the ipsilateral arm in 63% (67/106). There were 40 angiosarcomas and 76 sarcomas of other types. In a case-control study, angiosarcoma correlated significantly with lymphoedema of the arm, odds ratio (OR) 9.5 (95% CI 3.2-28.0), but no correlation with radiotherapy was observed. For other types of sarcoma there was a correlation with the integral dose. The dose-response relationship indicated that the risk increased linearly with the integral dose to 150-200 J and stabilised at higher energies. The OR was 2.4 (95% CI 1.4-4.2) for an energy of 50 J, approximately corresponding to the radiation of the breast after breast-conserving surgery. Thus, only oedema of the arm correlated with angiosarcoma, but for other types of sarcoma the integral dose of radiotherapy was a predictor of the risk.

Lymphedema: classification, diagnosis and therapy

This review presents the diagnostic features, the pathophysiology and the available therapies for lymphedema. This disease is often able to be diagnosed by its characteristic clinical presentation, yet, in some cases, ancillary tests might be necessary to establish the diagnosis, particularly in the early stages of the disease and in edemas of mixed etiology. These diagnostic modalities are also useful in clinical studies. Available modalities include isotopic lymphoscintigraphy, indirect and direct lymphography, magnetic resonance imaging, computed tomography and ultrasonography. Lymphedema may be primary or secondary to the presence of other disease and/or to the consequences of surgery. Primary lymphedema may occur at any phase of life but it most commonly appears at puberty. Secondary lymphedema is encountered more often. The most prevalent worldwide cause of lymphedema is filariasis, which is particularly common in south-east Asia. In the USA, postsurgical lymphedema of the extremity prevails. Complications of chronic limb lymphedema include recurrent cellulitis and lymphangiosarcoma. Most patients are treated conservatively, by means of various forms of compression therapy, including complex physical therapy, pneumatic pumps and compressive garments. Volume reducing surgery is performed rarely. Lymphatic microsurgery is still in an experimental stage, although a few centers consistently report favorable outcomes.

POST-MASTECTOMY SWELLING OF THE ARM: REVIEW OF THE LITERATURE AND PRELIMINARY REPORT OF 50 CASES

Images

Soft tissue sarcoma after treatment for breast cancer

In a register study all women in the West of Sweden Health Care Region with a breast cancer diagnosed between 1960 and 1980 (n = 13,490) were followed up in the Swedish Cancer Register to the end of 1988 for later occurrence of a soft tissue sarcoma (STS). Nineteen sarcomas were reported, whereas 8.7 were expected and the relative risk (RR) was 2.2 (CI 95% 1.3-3.4). The absolute risk was 1.7/10(4) person years (PY) in comparison with 0.8 expected. To obtain a more detailed analysis of the associations between arm lymphoedema, radiotherapy and STS development, and to control the quality of the register data, a case control study was also performed. Clinical records from the different hospitals in the region were collected for all the 19 cases as well as for three selected controls per case. The histopathology of the cases were reviewed, and one of the cases was reclassified as a malignant melanoma and excluded from further analysis. Thirteen of the cases were clustered around the treated breast area. To quantify the exposure to radiotherapy, the integral dose was estimated. The presence of lymphedema was included as a binary variable in the analysis. The exact conditional randomisation test indicated a significant correlation between the integral dose and the development of an STS (p = 0.008) and this association was still significant after stratification for arm oedema. A conditional logistic regression analysis with STS as the dependent variable and the integral dose as the explanatory variable gave an odds ratio (OR) of 5.2/100 J (CI 95% 1.3-21.2), and if this regression was restricted only to the STS developing in the radiation fields the OR was 3.2/100 J (CI 95% 0.8-12.9). Thus, the excess of STS in this breast cancer cohort was very low (0.9/10(4) PY). However the integral dose correlates well to the development of STS and can be useful in quantifying even small risks of secondary malignancies in the breast cancer population.

Elective hand surgery in the breast cancer patient with prior ipsilateral axillary dissection

BACKGROUND

We wished to determine if complications after elective hand surgery were greater in women with previous mastectomy and axillary dissection than in those without.

METHODS

We surveyed records of all women undergoing carpal tunnel release by the senior author (W.J.D.) from 1983 to 1993. The postaxillary dissection group (group A) was made up of 15 women; seven had some postdissection lymphedema. Group B was made up of 302 other patients who had not undergone breast surgery or axillary dissection. Anesthetic and surgical techniques were identical for both groups, with i.v. regional anesthesia used most commonly.

RESULTS

No patient in the axillary dissection group developed any postoperative infection or had any worsening of preexisting lymphedema or onset of new arm swelling after ipsilateral carpal tunnel release. The nonaxillary dissection group had a postoperative infection rate of 3.6%; all infections were superficial and resolved with conservative therapy. In addition, 31 women experienced other complications, including 13 with hand/finger stiffness and four with reflex dystrophy. Fifteen required formal hand therapy.

CONCLUSIONS

Women with prior ipsilateral axillary dissection can safely undergo elective upper extremity surgery, provided strict sterile technique and appropriate anesthetic and surgical precautions are observed. Patients having undergone previous axillary dissection should not be prohibited from future limb manipulations, including venepunctures, blood pressure measurements, or elective surgery.

Increased arterial inflow demonstrated by Doppler ultrasound in arm swelling following breast cancer treatment

Doppler ultrasound was used to estimate the mean arterial flow in the arms of 50 patients with arm oedema following breast cancer treatment (oedema group). They were compared with 26 treated breast cancer patients with no arm swelling (control group). Flows on the treatment side were expressed as a percentage of the flow in the contralateral normal arm. Mean percentage blood flow was 68% higher in the swollen arms than the contralateral normal arms compared to a mean increase of 38% on the breast cancer treatment side in the control group. In both groups there was a significantly higher proportion of patients with increased (> 150%) rather than decreased (< 50%) flow on the treatment side. The ratio of increased to decreased flow was 27:4 in the oedema group and 6:0 in the control group. A neurological deficit on the treatment side was associated with an increased incidence of higher flow on the same side in the oedema group. These findings demonstrate that breast cancer treatment results in a significant increase in arterial flow in the arm on the treatment side, and that this increase is even higher in those patients with swelling. Increased blood flow is likely to contribute to arm swelling. One explanation for increased flow would be neurological deficit with loss of sympathetic vasoconstrictor control.

Factors that influence the incidence of brachial oedema after treatment of breast cancer

Six factors that may increase the likelihood of swelling of the arm after treatment of breast cancer were investigated in 136 patients who had undergone treatment. The highest incidence of oedema was among patients who had received radiotherapy in high doses with few fractions to the axilla (60%), and in patients with a history of one or more infections in the arm on the operated side (89%). Overweight, oblique surgical incision, infection in the arm, and radiotherapy correlated with arm swelling. The age of the patient and whether the operation had been done on the dominant or non-dominant side correlated less with the incidence of oedema.

Importance of time in assessing arm and hand function after treatment of breast cancer

Ninety-three patients were examined on two occasions at 24-month intervals after surgery and irradiation for breast cancer. Stiffness of the shoulder joint, brachial oedema, pain in the arm, and the patients' subjective assessment of the degree of functional disability were registered. The results indicated that both oedema and stiffness of the shoulder joint are acceptable measures of functional impairment. We conclude, however, that such measurements should not be used as indicators of prognosis, because spontaneous improvement can occur for two years or more after treatment.

Late effects of adjuvant radiotherapy for breast cancer

Complications requiring in-hospital treatment were observed in 24 of 221 consecutively treated patients (11%) who were followed from 8 to 42 years after postmastectomy irradiation. There were four sarcomas of the treated chest wall, three squamous carcinomas (two in the esophagus), two angiosarcomas of the swollen homolateral arm, nine chronic ulcers, five respiratory insufficiencies, six pathologic fractures of the radiated shoulder or ribs, two fatal cardiomyopathies, one persisting leukopenia with fatal brain abscess, and one severe neurovascular impairment of the arm. In a comparable group of 394 consecutive postmastectomy patients who were not irradiated, one similar event, a myxosarcoma of an unswollen arm, was observed. Only long-term follow-up can determine the ultimate risks of radiotherapy.

Treatment results in mammary carcinoma stages I-IV

A retrospective review of 590 patients with breast carcinoma of all clinical stages is presented. The patients were treated mainly with radical mastectomy and postoperative irradiation. The overall 5- and 10-year survival rates were 59% and 45%, in stage I 83% and 76%, in stage II 64% and 47%, in stage III 29% and 14% and in stage IV 5% and 0%, respectively. Treatment methods, prognostic factors and differentiation grade of infiltrating ductogenic carcinoma have been analysed and the effect of these factors on the treatment results in different clinical stages is presented.

The prevention and management of lymphoedema after treatment for breast cancer

Lymphoedema of the arm is a disabling complication of surgery for cancer of the breast. It occurs in a significant proportion of patients and tends to occur later after the operation. Radiation increases the incidence. It needs to be differentiated for tumour recurrence and venous obstruction. Aetiology may include surgical technique, radiation and infection. Prevention is important as treatment is difficult. Treatment may include drugs, particularly benzopyrones, and enzymes, physiotherapy, elastic sleeves and surgery.

Nerve entrapments associated with postmastectomy lymphedema

Ninety females underwent mastectomy for breast cancer and were thereafter investigated to determine whether nerve entrapments were responsible for some of the disabling symptoms in their arms. The majority of these patients suffered from fullness (edema), numbness, paraesthesia, weakness and pain of the arm on the mastecotmized side. Lymphedema of varying degrees found in 50% of these patients was associated with brachial plexus entrapment and carpal tunnel syndrome (CTS). 28% of the patients has CTS, and 28% suffered from brachial plexus entrapment of the arm on the mastecotmized side, as compared with 8% and 5%, respectively, on the nonoperated side. 12% of the patients suffered from both types of entrapment. Thus we consider that brachial plexus entrapment and carpal tunnel syndrome should be added to the list of complications following mastectomy, with lymphedema playing an active part in their development.

Immunologic status and lymphedema of the arm in postoperative patients with cancer of the breast

Sixty women were evaluated regarding their immunologic status and for presence of lymphedema after surgery for breast carcinoma. Patients who had undergone radiotherapy were noted to have decreases in TLC, and increases in LIF. In addition, the patients also had an increased incidence of lymphedema after radical mastectomy.

Lymphedema of the upper limb after surgery for breast cancer

Radical mastectomy is followed by swelling of the arm, and although the number of surgeons employing the operation is decreasing, postmastectomy lymphedema continues to be a serious complication. In the present report based on 158 women who underwent modified radical (126) or simple (32) mastectomy and occasionally radiation for histologically proved adenocarcinoma of the breast, the pathogenesis and treatment of postmastectomy lymphedema are discussed. The following conclusions can be drawn: (1) The occurrence of postmastectomy lymphedema diminishes the less extensive the operation. (2) Mild lymphedema that develops early postoperatively tends to subside. (3) Conservative treatment in the majority of cases is effective in controlling postmastectomy lymphedema of a mild to moderate degree. (4) Modified radical mastectomy, which is as radical as Halsted's operation, is rarely followed by lymphedema.