Breast edema following staging axillary node dissection in patients with breast carcinoma treated by radical radiotherapy

Assessing Tissue Dielectric Constant Values in Tumor Bearing and Healthy Breasts

Background: This study aimed to investigate, characterize, and provide quantitative reference data on tissue dielectric constant (TDC) values of female breasts when measurements were made to 5 mm depths and determine the utility of these measurements to differentiate between benign and malignant breast tumors. Methods and Results: Breast TDC was measured bilaterally in 82 women just prior to an ultrasound-guided diagnostic biopsy of one tumor in one breast. TDC was measured in triplicate over the tumor and the contralateral healthy breast. Considering all paired breasts, the average TDC (mean ± SD) for healthy breasts was less than for tumor-bearing breasts (26.7 ± 4.5 vs. 29.9 ± 8.5, p = 0.0003). Conclusions: Breast TDC values measured to 5 mm in 82 healthy nonedematous breasts provide a two-SD threshold reference value of 35.7. This represents a TDC value above which the presence of breast edema/lymphedema may be indicated based on the two-SD threshold criterion. For unilateral cases, an interbreast TDC ratio exceeding 1.275 may be considered a breast edema/lymphedema indicator also based on the two SD criteria used. These thresholds may have utility for early detection and to track breast edema/lymphedema changes. A comparison of these TDC values obtained from benign versus malignant tumors indicates no statistically significant difference between them. However, interbreast TDC ratios were statistically higher for breasts with malignant versus benign tumors. However, the large overlap of the ratio values renders this method of discrimination between benign vs. malignant tumors inadequate based on the present findings.

Quantification of breast lymphoedema following conservative breast cancer treatment: a systematic review

PURPOSE

Breast lymphoedema is a possible side effect of breast conserving surgery, but it is poorly understood. This is due, in part, to difficulty assessing the breast. This systematic review described outcome measures that quantify breast lymphoedema signs and symptoms and evaluated the measurement properties for these outcome measures.

METHOD

Seven databases were searched using terms in four categories: breast cancer, lymphoedema and oedema, clinician reported (ClinROM) and patient reported outcome measures (PROM) and psychometric and measurement properties. Two reviewers independently reviewed studies and completed quality assessments. The Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) methodology was used for studies including measurement property evidence.

RESULTS

Fifty-six papers were included with thirteen questionnaires, eight patient-reported rating scales, seven physical measures, seven clinician-rating scales and four imaging techniques used to quantify breast lymphoedema. Based on COSMIN methodology, one ClinROM had sufficient reliability, ultrasound measuring dermal thickness. Tissue dielectric constant (TDC) measuring local tissue water had promising reliability. Four questionnaires had sufficient content validity (BLYSS, BLSQ, BrEQ and LYMQOL-Breast).

CONCLUSIONS

Ultrasound is recommended to reliably assess breast lymphoedema signs. No PROM can be recommended with confidence, but BLYSS, BLSQ, BrEQ and LYMQOL-Breast are promising. Further research is recommended to improve evidence of measurement properties for outcome measures.

IMPLICATIONS FOR CANCER SURVIVORS

There are many approaches to assess breast lymphoedema, but currently, only ultrasound can be recommended for use, with others, such as TDC and questionnaires, showing promise. Further research is required for all approaches to improve evidence of measurement properties.

Iatrogenic Breast Lymphoedema: Incidence, Diagnosis, and Associated Risk Factors

While upper limb lymphoedema following breast and axillary surgery is well established in the literature, breast lymphoedema is rarely documented. Our primary objective was to identify risk factors of breast lymphoedema, and our secondary aim was to assess the possibility of using a breast ultrasound scan to assess breast lymphoedema. This study was a case series analysis, including patients who had wide local excision for primary breast cancer treatment between January 2013 and January 2018. Patients' demographics, including age, weight, body mass index (BMI), breast volume, tumour characteristics, and histological findings, were noted. All patients had a clinical assessment and ultrasound scan 6 months and 12 months after surgery, comparing ipsilateral to the contralateral breast skin, subcutaneous thickness, as well as parenchymal changes. We have included two hundred eighty-six breast cancer; the mean age was 54.7 years SD 17.3, the mean weight was 76.5 kg SD 12.6, the mean BMI was 31.5 SD 5.2, and the mean breast volume was 1223 ml SD 179. This study identified breast lymphoedema in patients with clinically detected skin oedema in the absence of radiotherapy skin changes; skin and subcutaneous 5 mm added thickness more than the contralateral side, and based on that, 22 patients (7.7%) were found to have breast lymphoedema. We have also found that patients with high BMI, larger breast volume, upper outer quadrant tumours, and patients who had axillary lymph node clearance had an increased incidence of breast lymphoedema. The incidence of breast lymphoedema in this cohort was 7.7%. We suggest that breast lymphoedema should be considered if skin and subcutaneous thickness are 5 mm more than the contralateral side in the absence of severe radiotherapy skin changes. Also, we have found that high body mass index (BMI), larger breast volume, upper outer quadrant tumours, and patients who had axillary lymph node clearance are associated with an increased incidence of breast lymphoedema.

The Breast Edema Enigma: Features, Diagnosis, Treatment, and Recommendations

Breast edema most commonly occurs after breast cancer treatment involving breast-conserving therapy, although it may have a variety of other causes. As compared to research on breast cancer treatment-related lymphedema, breast edema and its objective measurement and diagnosis is far behind. Consequences of this disparity contribute to uncertainty and variability in its diagnosis, its treatment, and even the characterization of its incidence and morbidity. Moreover, consensus on a standardized definition, objective diagnostic method, and treatment techniques for breast edema has not yet been reached, making it difficult to provide appropriate guidelines with respect to its management. Given the recent rise in breast edema incidence as an outcome of the increasing use of breast-conserving therapy, this timely review examines the current state of breast edema assessment and makes a case for standardization in part via quantitative methods to diagnose and track breast edema.

Breast Tissue Dielectric Constant as a Potential Breast Edema Assessment Parameter

Background: Many methods can quantitatively assess limb lymphedema, but methods to assess breast edema/lymphedema are quite limited. Thus, there is a need for a convenient and accurate way to quantify and track changes in this condition. Herein, breast tissue dielectric constant (TDC) values that depend on tissue water were used to obtain reference TDC values and interbreast TDC ratios. Methods and Results: TDC was measured in both breasts of 61 women who were about to undergo an ultrasound-guided diagnostic biopsy of a single mass (tumor) in 1 breast. Patient age and body mass index were (mean ± SD) 65.1 ± 11.6 (41-87 years) and 28.9 ± 5.1 (19.1-43.7 kg/m2). TDC was measured at a standardized site (12 o'clock position) with the TDC probe placed with its outer edge at the periphery of the subareolar region. TDC values of healthy breasts versus tumor breasts showed tumor breasts 3% greater (30.4 ± 4.6 vs. 29.5 ± 4.6, p = 0.02). Patients with benign tumors (N = 33) showed no difference between breasts (30.5 ± 4.4 vs. 30.8 ± 4.6 p = 0.434) and had an interbreast TDC ratio (tumor breast/healthy breast) of 1.013 ± 0.077. Patients with malignant tumors (N = 28) had tumor breast values 5% greater (29.8 ± 4.8 vs. 28.4 ± 4.6, p = 0.018) and an interbreast ratio of 1.056 ± 0.117. The overall interbreast ratio (N = 61) was 1.033 ± 0.099. Conclusion: Breast TDC values from nonedematous breasts provide the basis for calculating potential edematous/lymphedematous threshold values based on the measured means +2.5 standard deviation (SD). Accordingly, a TDC threshold value of 41 and an interbreast ratio of 1.28 were determined. These parameters have potential applicability for early detection in at-risk patients and those suspected of having breast edema/lymphedema.

Breast edema, from diagnosis to treatment: state of the art

Introduction

Breast edema can arise from different etiologies; however, it is mostly seen after breast conserving surgery and/or radiotherapy. Combining breast conserving surgery and radiotherapy can cause damage to the lymphatic system and reactions to surrounding tissues, which can lead to breast edema; hereby, the breast size can increase by more than one cup size. Swelling of the breast is not the only criterion associated with breast edema. Other common criteria found in literature are peau d’orange, heaviness of the breast, skin thickening, breast pain, redness of the skin, hyperpigmented skin pores and a positive pitting sign. Despite the benefits of breast conserving surgery, breast edema can be uncomfortable, and can negatively influence quality of life in suffering patients. In contrast to lymphedema of the arm, which is well known in clinical practice and in research, breast edema is often underestimated and far less explored in literature. Currently, many aspects still need to be reviewed.

Purpose and importance to practice

This masterclass aims at providing the state of the art of breast edema for all health care workers and researchers involved in the treatment and monitoring of breast cancer patients. It includes current and future perspectives on its diagnosis, longitudinal course and treatment. Furthermore, recommendations for clinical practice and future research are discussed.

Clinical implications

It is recommended to closely monitor those patients in whom breast edema symptoms do not decline within 6 months after termination of radiotherapy and provide them with the appropriate therapy. Since evidence concerning the treatment of breast edema is currently lacking, we recommend the complex decongestive therapy (CDT) to the utmost extent, by analogy with the lymphedema treatment of the extremities. This treatment involves skin care, exercise therapy and compression. Additionally, all patients should be informed about the normal course of breast edema development.

Future research priorities

A consensus should be reached among clinicians and researchers concerning the definition, assessment methods and best treatment of breast edema. Furthermore, high quality studies are necessary to prove the effectiveness of the CDT for breast edema.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40945-021-00103-4.

Breast Lymphedema After Conservative Breast Surgery: An Up-to-date Systematic Review

Although arm lymphedema following breast cancer treatment is a common complication; breast lymphedema following treatment is not uncommon. Several risk factors were found to contribute to breast lymphedema, including axillary surgery, high body mass index (BMI), increased bra cup size, adjuvant chemotherapy, locoregional and radiotherapy boost, and upper outer quadrant tumors. We aimed to provide a review to help avoiding or management of breast lymphedema. The search term 'breast lymphedema' was combined with 'breast conservative surgery' and was used to conduct a literature research in PubMed and Medline. The term lymphedema was combined with breast, conservative, and surgery to search the Embase database. All papers published in English were included with no exclusion date limits. A total of 2155 female patients were included in this review; age ranged from 26 to 90 years. The mean BMI was 28.4 of the studies that included patients who underwent conservative breast surgery. Incidence of breast lymphedema ranged from 24.8% to 90.4%. Several risk factors were linked to breast lymphedema after conservative breast surgery, such as BMI, breast size, tumor size, tumor site, type of surgery, and adjuvant therapy. Treatment options focused on decongestive lymphatic therapy, including manual lymphatic drainage, self-massaging, compression bras, or Kinesio taping. Breast lymphedema is a relatively common complication, yet there is no clear consensus on the definition or treatment options.

Utility of indocyanine green injection in patients with cervical cancer besides the identification of sentinel lymph node (Review)

Due to the wide introduction of screening tests, patients with neoplastic diseases of the uterine cervix trend to be diagnosed in early stages of the disease, and less invasive surgical procedures are needed in certain cases. In this respect, the technique of sentinel lymph node dissection has been widely implemented as part of the therapeutic strategy, indocyanine green (ICG) being one of the most reliable markers for sentinel lymph node detection. However, it seems that this agent is extremely useful in order to achieve better short-term and long-term results after cervical cancer surgery, due to its capacity to determine the uterine vascular perfusion in cases in which conservative treatment, such as trachelectomy, is performed, as well as to prevent and treat lower limb lymphedema. A literature review was conducted of the studies which focused on the role of ICG utility in cervical cancer patients besides sentinel lymph node detection, special focus was given to vascularization preservation and lower limb lymphedema prevention and treatment.

Lymphovenous anastomosis (LVA) for treatment of secondary breast lymphedema: A case report and literature review

Breast lymphedema (BLE) is a rather common complication occurring after surgical breast cancer treatment. Microsurgical lymphovenous anastomosis (LVA) is a validated technique for the management of lymphedema in the extremities and it is gaining approval also for the breast one. Here, we report a case of breast lymphedema successfully treated with LVA. A 52 years old woman referred chronic erythema, diffuse swelling and pain after breast surgery, axillary lymphnode dissection and adjuvant radiotherapy. Conservative treatments had been performed for 14 months without improvement of symptoms. The patient was then referred for surgery and multiple LVAs were performed at the right breast. A total of 3 LVAs have been performed, two lymphatic vessels were anastomosed to a single Y-shaped vein and one additional vessel was linked to another nearby vein of similar caliber. All the LVAs were executed using 12-0 microsutures and their patency was confirmed with intraoperative ICG lymphography. Immediately after this intervention the swelling decreased in size and the erythema disappeared and a sensation of relief was reported by the patient. The postoperative course was uneventful and at the 6 and 12 months follow up no signs and symptoms of recurrence were noted. Therefore, we believe that this case adds another significant evidence of the efficacy of LVA for treatment of secondary BLE refractory to conservative treatment. Moreover, we provide a literature review of previous reports of breast lymphedema treated recurring to this procedure.

Assessing breast lymphoedema following breast cancer treatment using indocyanine green lymphography

PURPOSE

Breast lymphoedema is a largely unrecognised survivorship issue for women following breast cancer treatment. While a few objective methods have previously been applied to assess breast lymphoedema, none are capable of imaging breast lymphatics or identifying lymphatic morphological changes indicative of breast lymphoedema. The purpose of this study was to determine if indocyanine green (ICG) lymphography, a validated assessment technique in breast cancer-related lymphoedema), can visualise breast lymphatics and identify breast lymphoedema. Additionally, ICG lymphography was utilised to investigate lymphatic drainage pathways of the affected breast following breast-conserving therapy.

METHODS

Twenty female participants (10 breast lymphoedema and 10 healthy controls) were recruited for this pilot study. All underwent a medical history, physical breast assessment, tissue dielectric constant measures of breast water content, and ICG lymphography.

RESULTS

ICG lymphography identified lymphatic morphological changes in all breast lymphoedema participants (dermal backflow patterns = 10, collateral lymphatic drainage = 9) and none in the control group. The dominant lymphatic drainage pathway to the ipsilateral axilla was observed in all control participants but in only four breast lymphoedema participants. Collateral drainage pathways in the breast lymphoedema group were to: parasternal (6/10); contralateral axilla (4/10); intercostal (3/10); and clavicular (2/10) regions.

CONCLUSION

These findings suggest ICG lymphography, through the identification of morphological lymphatic changes, is a potential qualitative objective assessment technique for breast lymphoedema. Furthermore, in this group of breast lymphoedema patients it identified changes to the normal drainage pathway of the breast. Understanding these changes will have implications for clinical management.

Development and clinimetric properties of the Dutch Breast Edema Questionnaire (BrEQ-Dutch version) to diagnose the presence of breast edema in breast cancer patients

PURPOSE

To develop a diagnostic tool, the Breast Edema Questionnaire (BrEQ) and to determine its clinimetric properties.

METHODS

The BrEQ was developed based on information from literature, experts and breast edema patients. Content validity, construct validity, test-retest reliability, internal consistency and cut-off point were investigated in a group of breast cancer patients. Construct validity made up two parts; convergent and known-groups validity. Convergent validity was tested by correlating the BrEQ with skin thickness measured with ultrasound (US).

RESULTS

In part 1 of the BrEQ, symptoms of breast edema were scored from 0 to 10: pain, heaviness, swelling, tensed skin, redness, pitting sign, enlarged skin pores and hardness. Taking into account the International Classification of Functioning, Disability and Health, several activity limitations and participation restrictions were scored from 0 to 10 in part 2. Clinimetric properties of part 1 were examined in 55 patients. US showed that 35 women had breast edema. Content validity was good. Regarding convergent validity, all breast symptoms correlated moderately with skin thickness. The total symptom score had a strong correlation with skin thickness. Concerning known-groups validity, patients with breast edema had a higher total symptom score. Test-retest reliability ranged between moderate and strong. The internal consistency was good for all items and the total symptom score. We identified that a score cut-off point of ≥ 8.5 discriminates between patients with breast edema and those without.

CONCLUSION

Part 1 of the BrEQ-Dutch version is a valid and reliable tool for assessing clinical indicators of breast edema.

Successful Relief of a Male Breast Lymphedema by Supermicrosurgical Lymphaticovenular Anastomosis

BACKGROUND

Breast lymphedema is a common issue after breast cancer surgery but remains understudied because it is difficult to be quantified. Untreated breast lymphedema may lead to severe form of delayed breast cellulitis. Supermicrosurgical lymphaticovenular anastomosis is one option for the treatment of breast cancer-related lymphedema but has not been described for the treatment of breast lymphedema.

METHODS

This report presented a rare case of male breast lymphedema secondary to axillary lymph node dissection for the treatment of a forearm melanoma. Deep lymphatic vessels and adjacent venules were individualized under high magnification in the periareolar area. Six lymphaticovenular anastomoses were performed using supermicrosurgical techniques. A clinical examination and a volume assessment under magnetic resonance imaging were used to assess the efficiency of surgery.

RESULTS

Postoperative outcome was uneventful. The patient was followed-up during 1 year. Swelling relief was clinically significant 3 months postoperatively. The pinch test reduction was 2 cm after 12 months. The breast volume reduction rate was 47.2%.

CONCLUSIONS

Supermicrosurgical lymphaticovenular anastomosis may be efficient for the treatment of postoperative breast lymphedema, even in male patients.

Predictive factors for persistent and late radiation complications in breast cancer survivors

PURPOSE

With improved diagnostic techniques and treatments of breast cancer, overall survival times are longer, giving more opportunity for normal tissue complications of treatment to manifest. Radiation late effects (RLEs) could have profound long-term impacts on the quality of life of the survivors. The aim of this study was to identify predictive factors influencing timing and types of complications in patients referred to the Adult Radiation Late Effects Clinic (ARLEC).

METHODS

In a period of 16 years, 296 breast cancer patients were referred to the ARLEC. The clinical records were retrospectively studied to collect epidemiologic, medical and treatment data. Associations were sought between candidate predictive factors and time to the first complication after radiation treatment (RT) completion (primary outcome), and pain or swelling (secondary outcomes) using univariable and multivariable linear and logistic regression analyses. All analyses were performed in SAS, version 9.4.

RESULTS

All patients were female with a mean age of 56.3 years. The first treatment-related complication occurred after a median of 3 months. Patients were followed at ARLEC for a median of 18 months. Older age and delay from surgery to RT (S-RT delay) were associated with earlier onset of complications (both p < 0.001). The most common complications were breast pain (62.1%) and swelling (45.9%). Histology and RT boost were associated with pain (p = 0.035 and 0.013). RT boost and S-RT delay on the other hand were associated with swelling (p = 0.013 and 0.005).

CONCLUSIONS

Clinical factors identified could help recognize the patients at high risk for developing RLEs and alert physicians to initiate earlier diagnostic and therapeutic measures.

Patterns of lymphatic drainage after axillary node dissection impact arm lymphoedema severity: A review of animal and clinical imaging studies

Upper extremity lymphoedema after axillary node dissection is an iatrogenic disease particularly associated with treatment for breast or skin cancer. Anatomical studies and lymphangiography in healthy subjects identified that axillary node dissection removes a segment of the lymphatic drainage pathway running from the upper limb to the sub-clavicular vein, creating a surgical break. It is reasonable to infer that different patterns of lymphatic drainage may occur in the upper limb following surgery and contribute to the various presentations of lymphoedema from none to severe. Firstly, we reviewed animal imaging studies that investigated the repair of lymphatic drainage pathways from the limb after lymph node dissection. Secondly, we examined clinical imaging studies of lymphatic drainage pathways after axillary node dissection, including lymphangiography, lymphoscintigraphy and indocyanine green fluorescence lymphography. Finally, based on the gathered data, we devised a set of general principles for the restoration of lymphatic pathways after surgery. Lymphoscintigraphy shows that restoration of the original lymphatic pathway to the axilla after its initial disruption by nodal dissection was not uncommon and may prevent lymphoedema. We found that regenerated lymphatic vessels and dermal backflow (the reflux of lymph to the skin) contributed to either restoration of the original pathway or rerouting of the lymphatic pathway to other regional nodes. Variation in the lymphatic drainage pathway and the mechanisms of fluid drainage itself are the foundation of new lymphatic drainage patterns considered to be significant in determining the severity with which lymphoedema develops.

Safety and benefit of using a virtual bolus during treatment planning for breast cancer treated with arc therapy

Purpose

This study evaluates the benefit of a virtual bolus method for volumetric modulated arc therapy (VMAT) plan optimization to compensate breast modifications that may occur during breast treatment.

Methods

Ten files were replanned with VMAT giving 50 Gy to the breast and 47 Gy to the nodes within 25 fractions. The planning process used a virtual bolus for the first optimization, then the monitors units were reoptimized without bolus, after fixing the segments shapes. Structures and treatment planning were exported on a second scanner (CT) performed during treatment as a consequence to modifications in patient's anatomy. The comparative end‐point was clinical target volume's coverage. The first analysis compared the VMAT plans made using the virtual bolus method (VB‐VMAT) to the plans without using it (NoVB‐VMAT) on the first simulation CT. Then, the same analysis was performed on the second CT. Finally, the level of degradation of target volume coverage between the two CT using VB‐VMAT was compared to results using a standard technique of forward‐planned multisegment technique (Tan‐IMRT).

Results

Using a virtual bolus for VMAT does not degrade dosimetric results on the first CT. No significant result in favor of the NoVB‐VMAT plans was noted. The VB‐VMAT method led to significant better dose distribution on a second CT with modified anatomies compared to NoVB‐VMAT. The clinical target volume's coverage by 95% (V95%) of the prescribed dose was 98.9% [96.1–99.6] on the second CT for VB‐VMAT compared to 92.6% [85.2–97.7] for NoVB‐VMAT (P = 0.0002). The degradation of the target volume coverage for VB‐VMAT is not worse than for Tan‐IMRT: the median differential of V95% between the two CT was 0.9% for VMAT and 0.7% for Tan‐IMRT (P = 1).

Conclusion

This study confirms the safety and benefit of using a virtual bolus during the VMAT planning process to compensate potential breast shape modifications.

Unusual Breast Edema and Erythema during Radiotherapy in the Conservative Approach of Breast Cancer. A Case Report

The appearance of breast edema in the conservative approach of breast cancer is correlated with axillary dissection, and it is worsened by radiotherapy. In rare cases there are serious edema and erythema of the breast at the beginning of radiotherapy. We present a patient with edema and erythema of the breast with an unusual evolution after conservative surgical treatment of the breast cancer. Possible etiologies and published data are reviewed.

Patient-reported Quality of Life and Satisfaction With Cosmetic Outcomes After Breast Conservation and Mastectomy With and Without Reconstruction: Results of a Survey of Breast Cancer Survivors

OBJECTIVE

Although breast conservation is therapeutically equivalent to mastectomy for most patients with early-stage breast cancer, an increasing number of patients are pursuing mastectomy, which may be followed by breast reconstruction. We sought to evaluate long-term quality of life and cosmetic outcomes after different locoregional management approaches, as perceived by patients themselves.

METHODS

We surveyed women with a diagnosis of nonmetastatic breast cancer from 2005 to 2007, as reported to the Los Angeles and Detroit population-based Surveillance, Epidemiology, and End Results registries. We received responses from 2290 women approximately 9 months after diagnosis (73% response rate) and from 1536 of these 4 years later. We evaluated quality of life and patterns and correlates of satisfaction with cosmetic outcomes overall and, more specifically, within the subgroup undergoing mastectomy with reconstruction, using multivariable linear regression.

RESULTS

Of the 1450 patients who responded to both surveys and experienced no recurrence, 963 underwent breast-conserving surgery, 263 mastectomy without reconstruction, and 222 mastectomy with reconstruction. Cosmetic satisfaction was similar between those receiving breast conservation therapy and those receiving mastectomy with reconstruction. Among patients receiving mastectomy with reconstruction, reconstruction type and radiation receipt were associated with satisfaction (P < 0.001), with an adjusted scaled satisfaction score of 4.7 for patients receiving autologous reconstruction without radiation, 4.4 for patients receiving autologous reconstruction and radiation therapy, 4.1 for patients receiving implant reconstruction without radiation therapy, and 2.8 for patients receiving implant reconstruction and radiation therapy.

CONCLUSIONS

Patient-reported cosmetic satisfaction was similar after breast conservation and after mastectomy with reconstruction. In patients undergoing postmastectomy radiation, the use of autologous reconstruction may mitigate the deleterious impact of radiation on cosmetic outcomes.

Breast edema in breast cancer patients following breast-conserving surgery and radiotherapy: a systematic review

Breast-conserving surgery (BCS) is commonly used in breast cancer treatment. Despite its benefits, some women will be troubled by breast edema. Breast edema may cause an unsatisfactory cosmetic result, influencing the quality of life. The purpose of this systematic review is to investigate the incidence of breast edema and to identify risk factors of breast edema in breast cancer patients following BCS and radiotherapy. A systematic literature search was performed using different electronic databases (PubMed, Web of Science, Cochrane, Embase) until June 2014. Inclusion criteria were as follows: (1) research studies that included female breast cancer patients who were treated with BCS and radiotherapy and (2) studies that investigated the incidence of breast edema and/or risk factors of breast edema. Exclusion criteria were (1) reviews or case studies and (2) studies published before 1995. We identified in total 28 papers which represented 4,011 patients. There was a great variation in the incidence of breast edema (0-90.4 %). We identified several possible risk factors for breast edema namely increasing irradiated breast volume, increasing boost volume, the use of a photon boost, increasing breast separation, a higher density of the breast tissue, a large tumor, a higher specimen weight, postoperative infection, acute postoperative toxicity, and diabetes mellitus. However, their prognostic value remains uncertain. Breast edema is a common complaint after BCS and radiotherapy. A number of possible risk factors associated with breast edema were identified, but further research is warranted.

Risk factors associated with breast lymphedema

BACKGROUND

The development of breast lymphedema (BLE) after breast/axillary surgery is poorly characterized. We prospectively evaluated clinical and surgical factors associated with development of BLE.

METHODS

Patients undergoing unilateral breast-conserving surgery were prospectively enrolled preoperatively and followed for development of BLE. To augment the number of patients with BLE for evaluation of risk factors, postoperative patients identified in the clinic with signs and symptoms of BLE were also enrolled. Logistic regression with Firth's penalized likelihood bias-reduction method was used for univariate and multivariate analysis.

RESULTS

Of 144 women, 124 were enrolled preoperatively (38 of whom developed BLE), and 20 women with BLE were enrolled postoperatively. Any type of axillary surgery was the strongest factor associated with BLE (odds ratio, 134; 95 % confidence interval, 18 to >1,000). All 58 BLE events occurred in women with axillary surgery as compared with no events in the 46 patients without axillary surgery (p < 0.0001). Among 98 women who underwent axillary surgery, BLE did not occur more often after axillary lymph node dissection versus sentinel lymph node biopsy (p = 0.38) and was not associated with total number of nodes removed (p = 0.52). In multivariate analysis, factors associated with the development of BLE in the axillary surgery subgroup included baseline BMI (p = 0.004), incision location (p = 0.009), and prior surgical biopsy (p = 0.01).

CONCLUSIONS

Risk of BLE is primarily related to performance of any axillary surgery but not the extent of axillary surgery or number of lymph nodes removed. Other factors associated with BLE were increased body mass index, incision location, and prior surgical excisional biopsy.

Significance of popliteal lymph nodes visualization during radionuclide lymphoscintigraphy for lower limb lymphedema

Purpose:

To examine the frequency and significance of visualization of popliteal nodes during lymphoscintigraphy for the investigation of lower extremity swelling.

Materials and Methods:

Technetium-99m-labeled nanocolloid was injected subcutaneously in the first web spaces of both feet of 90 patients (24 males, 66 females; age range, 4-70 years) who had clinical evidence of lower limb lymphedema and were referred for routine lymphoscintigraphy; imaging was performed 5, and 90 minutes after injection without any vigorous exercise between the injection and imaging.

Results:

According to the scan findings, patients were divided into two groups; group I included 63 patients without popliteal nodes visualization on scanning, and group II included 27 patients with positive popliteal nodes uptake. None of patients with primary lymphedema (N = 22) due to agenesis or hypoplasia showed popliteal node uptake, whereas, patients with secondary lymphedema (N = 68) had either severe (N = 23) or partial (N = 45) lymphatic obstruction. A high positive association of popliteal node uptake with the severity of lymphatic obstruction was noted. Popliteal nodes were visualized in 26 of 57 patients with dermal back flow (46%), and in only 1 of 33 patients without dermal back flow (3%). There was a strong association between skin rerouting and popliteal node visualization (P < 0.01). Skin changes were detected in 24 patients (38%) with positive popliteal node uptake.

Conclusion:

Popliteal lymph nodes uptake during lymphoscintigraphy for clinical lymphedema of the lower limb indicates lymph rerouting through the deep system and raises a diagnosis of higher severity and longer duration of lymphatic dysfunction.

Supportive care during treatment for breast cancer: resource allocations in low- and middle-income countries. A Breast Health Global Initiative 2013 consensus statement

Breast cancer patients may have unmet supportive care needs during treatment, including symptom management of treatment-related toxicities, and educational, psychosocial, and spiritual needs. Delivery of supportive care is often a low priority in low- and middle-income settings, and is also dependent on resources available. This consensus statement describes twelve key recommendations for supportive care during treatment in low- and middle-income countries, identified by an expert international panel as part of the 5th Breast Health Global Initiative (BHGI) Global Summit for Supportive Care, which was held in October 2012, in Vienna, Austria. Panel recommendations are presented in a 4-tier resource-stratified table to illustrate how health systems can provide supportive care services during treatment to breast cancer patients, starting at a basic level of resource allocation and incrementally adding program resources as they become available. These recommendations include: health professional and patient and family education; management of treatment related toxicities, management of treatment-related symptoms of fatigue, insomnia and non-specific pain, and management of psychosocial and spiritual issues related to breast cancer treatment. Establishing supportive care during breast cancer treatment will help ensure that breast cancer patients receive comprehensive care that can help 1) improve adherence to treatment recommendations, 2) manage treatment-related toxicities and other treatment related symptoms, and 3) address the psychosocial and spiritual aspects of breast cancer and breast cancer treatments.

A prospective study of breast lymphedema: frequency, symptoms, and quality of life

Although lymphedema of the arm is a well-known complication of breast and axillary surgery, breast lymphedema has received scant attention. We sought to prospectively characterize breast lymphedema's incidence, associated symptoms, clinical course, and impact on quality of life. Subjects were enrolled prospectively from a consecutive sample of patients undergoing non-mastectomy breast procedures (excisional biopsy or wide local excision ± lymph node removal) and followed for signs and symptoms of lymphedema in the operated breast. Symptoms and distress were serially assessed with 11-point linear analog scales. Breast lymphedema was diagnosed independent of symptoms, based on the distribution and degree of edema and erythema. One hundred twenty-four women were followed for a median of 11 months, and breast lymphedema was diagnosed in 38 (31%) women. Breast lymphedema was more frequent after breast surgery with axillary node removal (49%) compared to breast surgery alone (0%), p < 0.0001. Breast lymphedema involved multiple quadrants in most women and was characterized by edema in 100% and erythema in 79%. Patients with breast lymphedema were significantly more likely than women without breast lymphedema to report symptoms of breast heaviness (65% vs 22%, p < 0.0001), redness (62% vs 29%, p = 0.0006), and swelling (59% vs 22%, p < 0.0001), but symptom-associated distress was low overall. Three of 32 breast lymphedema patients with clinical follow-up developed chronic edema. Breast lymphedema occurs in approximately one-half of women who undergo breast surgery with axillary node removal. The condition is characterized by diffuse skin edema and erythema as well as self-reported symptoms with a low level of distress.

Breast lymphedema after breast conserving treatment

The authors aimed to evaluate breast lymphedema after breast conserving therapy (BCT) and sentinel node biopsy (SNB) or axillary clearance (AC). Fifty-seven breast cancer patients with BCT underwent SNB only and 103 underwent AC (57 with tumor negative and 46 with positive axillary nodes). Clinical examination and breast ultrasonography (US) were performed one year after surgery. Clinical examination revealed breast edema in 48% of patients in the AC node positive group, in 35% in the AC node negative group, and in 23% in the SNB group (p<0.05 between SNB and AC node positive). US revealed subcutaneous edema in the operated breast in 69-70% of the patients in the AC groups and in 28% in the SNB group (p=0.001-0.0001 between the SNB and the AC groups). Breast lymphedema was less common one year after BCT in patients with SNB only than in those with more extensive axillary treatment.

Breast Edema in Patients Undergoing Breast-Conserving Treatment for Breast Cancer: Assessment via High Frequency Ultrasound

To identify factors that can influence breast edema in women undergoing breast-conserving therapy. Breast edema was assessed clinically and via high frequency ultrasound (HFUS) prior to, during and following radiotherapy. Fifty-four women were assessed. Breast edema was present prior to radiotherapy in patients who had undergone level 2 node dissection or had wound infection after sentinel node dissection. Edema increased during and after radiotherapy and peaked at 4-6 months. The time course of breast edema was related to the extent of nodal dissection, postoperative wound infection and regional radiotherapy. HFUS prior to irradiation was found to be no better than clinical assessment in predicting prolonged parenchymal breast edema but was significantly better at the end of irradiation. Breast edema levels are minimal in patients who do not undergo axillary node dissection or have an uncomplicated sentinel node dissection. Most edema is due to compromise of the draining lymphatics, which relates largely to the extent of axillary node dissection. HFUS appears to be a useful in the research setting in quantifying the effect of techniques that aim to reduce complications such as edema.

Advances in Radiation Treatment of Patients With Breast Cancer

Breast cancer is the most commonly diagnosed cancer among women in the United States. Approximately half of all patients diagnosed with early-stage breast cancer receive conservative breast surgery followed by consolidative radiation treatment. A number of technologic advances have been made in radiation therapy planning and treatment that minimize early and late toxicities and may improve treatment outcomes. Among these are (a) the treatment of patients with large or pendulous breasts or cardiopulmonary disease in the prone position, (b) intensity-modulated radiation treatment, which delivers precise, highly conformal radiation dose distributions within the breast by using computerized inverse treatment planning and intensity-modulated radiation beams to produce the required dose distribution, and (c) brachytherapy, which is the placement of a radioactive source within the lumpectomy bed. These advances are gaining national recognition and are available at many institutions. Nurses play a vital role in educating patients; therefore, nurses must have the information they need to inform their patients about these advances. The information in this article will allow nurses to help patients understand the anticipated treatment and related side effects and make informed decisions.

Radiation therapy after breast-conserving surgery

The authors critically reviewed previous articles concerning the significance of breast irradiation following breast-conserving surgery in terms of the following subject items: indications for breast-conserving therapy, the significance and complications of breast irradiation, the timing of the start of breast irradiation, the significance of boost irradiation, the potential improvement of survival with systemic therapy plus breast irradiation, the significance of axillary dissection, indications and the significance of regional nodal irradiation, accelerated hypofractionated radiotherapy, omission of breast irradiation in low-risk patients, and future directions. In addition, our previously reported results of breast irradiation following breast-conserving surgery at the Keio University Hospital are outlined. Our newly developed tangential irradiation technique directed to the axilla and a recently introduced three-dimensional simulation technique for radiotherapy treatment planning are also presented.

Angiosarcoma after conservation treatment for breast carcinoma: Our experience and a review of the literature

The development of angiosarcoma of the breast is a recognized complication of breast conservation therapy (BCT), but the evolution, prevalence, and outcome have not been accurately established. We sought to evaluate and review the clinicopathologic, prognostic, and treatment attributes of angiosarcoma arising in the irradiated breast after BCT. We conducted a retrospective chart and slide review of 8 patients seen between 1996 and 2004 with a diagnosis of secondary angiosarcoma. All were treated with mastectomy. Clinical and histopathologic findings were studied and previously reported cases were reviewed. Primary surgery-related breast edema and cellulitis was observed in 7 and 5 patients of the 8 patients studied, respectively. Postirradiation breast edema and grade 2/3 fibrosis occurred in 5 and 8 patients, respectively. The mean age of the patients at onset of the breast cancer and angiosarcoma was 65 and 72 years, respectively. The mean latency period between the treatment of the breast cancer and the diagnosis of angiosarcoma was 75 months. The actuarial rate of 2-year survival for patients presented with single (n = 4) compared with multiple (n = 4) skin lesions was 50% and 0%, respectively (P = .0233). The estimated incidence of angiosarcoma after BCT was found to be 0.14 %. BCT-associated angiosarcoma arises after a relatively brief interval, and breast edema-fibrosis can possibly contribute to its development. Special attention should be paid to skin changes occurring after BCT. The extent of skin lesions is predictive of survival. As shown by a review of the literature, angiosarcomas are often resistant to surgery, chemotherapy, and radiotherapy, and targeted therapy against tumor biological properties may be a new approach to angiosarcoma treatment.

A longitudinal study of symptoms and self-care activities in women treated with primary radiotherapy for breast cancer

The purpose of this prospective longitudinal study was to describe the occurrence, severity, and pattern of symptoms experienced by women during and after primary radiation therapy for breast cancer. A convenience sample of 30 women was recruited from a community hospital. The Symptom Profile by King et al (Oncology Nursing Forum. 1985;12(4):55-61) was adapted to measure 11 symptoms, and the Profile of Mood States assessed psychological status. Data were collected weekly during radiation and monthly for 3 months after treatment. There was a pattern of increasing incidence during treatment for the most commonly reported symptoms: fatigue (33%-93%), skin changes (36%-100%), sensation changes (28%-79%), and breast swelling (11%-38%), with gradual improvement over the following 3 months. Sleep problems were reported by nearly half of the subjects during and after treatment. Severity ratings of symptoms were mild to moderate but significantly higher by the end of therapy (P </= .01). There were no significant differences in psychological mood states during or after treatment except for the fatigue subscale (P </= .05). These findings will assist the nurse in preparing women for predictable symptoms during and after a course of breast irradiation and direct assessment, and provide data to support evidence-based interventions to minimize symptom distress.

Cosmetic outcome of breast conserving therapy after sentinel node biopsy versus axillary lymph node dissection

INTRODUCTION

Next to locoregional control, good cosmetic outcome is one of the main goals of breast conserving treatment (BCT) for breast cancer surgery. Factors affecting cosmetic outcome are well known. The sentinel node (SN) procedure avoids lymphedema in the breast, which might influence cosmetic outcome. The aim of this study was to evaluate the cosmetic outcome of BCT after the SN procedure compared to that after axillary lymph node dissection (ALND).

METHODS

The subjects were 20 patients who underwent ALND and 20 patients who underwent the SN procedure. After a minimum follow-up period of 43 months, we photographed each patient. Fifteen healthy women served as control subjects. We used the percentage breast retraction assessment index (pBRA=BRA/reference length x 100) to compare cosmetic outcome.

RESULTS

The median pBRAs of the ALND group and SN group (14.3 and 6.71, respectively) significantly differed ( p=0.001). The pBRA of the SN group was comparable to the pBRA (6.1) of the control group ( p=0.317).

CONCLUSION

Cosmetic outcome of BCT after the SN procedure was superior compared to the cosmetic outcome after ALND. This is an important additional reason to implement the SN procedure in routine daily practice.

Risk of Angiosarcoma Following Breast Conservation: A Clinical Alert

Approximately 100 cases of angiosarcoma following breast-conserving therapy have been reported. The prevalence of angiosarcoma following breast conservation has not been accurately established and optimal treatment has not been defined. The goal of this article is to clarify both issues. The Fisher's exact test was used to compare the prevalence of postirradiation angiosarcoma seen in our private practice to the prevalence reported from the two largest national database studies. A literature review was performed to determine optimal treatment guidelines. The results of the comparison indicated that the prevalence of postirradiation angiosarcoma seen in our practice was significantly higher than that reported in the two national database studies at p-values of 0.0124 and 0.0080. Also, results from the literature review suggest that early detection and aggressive treatment lead to improved outcomes. The data are insufficient to draw firm conclusions, but suggest that the current literature underestimates the prevalence of angiosarcoma following breast-conserving therapy. Since elderly women derive less benefit from radiation and may be more prone to develop postirradiation angiosarcoma, confirmation of our findings could lead to a reappraisal of the management of elderly patients with early stage breast cancer.

Unilateral breast edema: spectrum of etiologies and imaging appearances

Breast edema is defined as a mammographic pattern of skin thickening, increased parenchymal density, and interstitial marking. It can be caused by benign or malignant diseases, as a result of a tumor in the dermal lymphatics of the breast, lymphatic congestion caused by breast, lymphatic drainage obstruction, or by congestive heart failure. Here we describe several conditions, that cause unilateral breast edema with the aim of familiarizing radiologists with these disease entities.

Localized scleroderma in a woman irradiated at two sites for endometrial and breast carcinoma: a case history and a review of the literature

Localized scleroderma is an uncommon side-effect of radiotherapy. We report a unique case with multiple asynchronous primary malignant tumors, which developed localized scleroderma after radiotherapy. A 67-year-old healthy woman received external irradiation for endometrial cancer. Three years later she underwent partial mastectomy and postoperative radiotherapy because of breast cancer. A progressive fibrosis developed in the breast. Within 12 months similar skin reactions were also seen in the irradiated abdominal wall and on both lower extremities. Biopsies revealed scleroderma lesions of breast and abdominal wall and scleroderma-like lesions on the legs. The lesions dissolved partially without generalization. This case, in contrast to most of the cases previously reported in the literature, illustrates not only lesions outside of radiation ports, but also that radiotherapy given to one cancer site can affect distant skin at a previously irradiated cancer site. When a localized scleroderma is diagnosed, further curative radiotherapy should be cautiously prescribed irrespective of cancer site.

Cosmetic assessment of breast-conserving surgery for primary breast cancer

The goals of breast-conserving treatment are to achieve local control and survival rates equivalent to mastectomy and to preserve breast cosmetic appearance. This paper specifically addresses the different ways of cosmetic assessment by the observer (subjective and objective assessments) and by the patient (self-assessment), and the factors which influence the cosmetic outcome, based on a review of the current literature.

The impact of prophylactic axillary node dissection on breast cancer survival--a Bayesian meta-analysis

BACKGROUND

Because of the general acceptance of the NSABP B-04 study, prophylactic axillary node dissection for women with clinically negative axillae is considered diagnostic, but not therapeutic, by many oncologists. Nevertheless, several authors have shown that B-04 did not include enough patients to exclude a small survival advantage.

METHODS

A Bayesian meta-analysis of the available literature was performed comparing standard treatment to standard treatment without axillary node dissection. Six randomized controlled trials were identified, consisting of nearly 3000 patients and spanning four decades.

RESULTS

All six trials showed that prophylactic axillary node dissection improved survival, ranging from 4% to 16%, corresponding to a risk reduction of 7%-46%. Combining the six trials showed an average survival benefit of 5.4% (95% CI = 2.7-8.0%, probability of survival benefit > 99.5%). Adjusting for biases in the individual studies did not alter the conclusions, nor did subset analysis of Stage I patients.

CONCLUSIONS

Axillary node dissection improves survival in women with operable breast cancer. Nevertheless, two important limitations of this analysis are noteworthy. Few of the patients in the six trials had T1a tumors, so extrapolation of these results to this subset (and those with nonpalpable tumors) may be inappropriate. Essentially no patients in the six trials were treated with adjuvant therapy, as contrasted to current clinical practice. It is possible that the risk reduction seen in this meta-analysis may be diminished in patients receiving adjuvant chemotherapy. Despite these limitations, this study suggests that axillary dissection should be performed in most women with palpable tumors for diagnostic, as well as therapeutic, purposes.

[Radiation-induced sarcoma after breast cancer. Apropos of 8 cases and review of the literature]

PURPOSE

Retrospective analysis of eight new cases of radiation-induced sarcomas following radiotherapy for breast carcinoma and literature review.

PATIENTS AND METHODS

Eleven patients presenting with radiation-induced sarcoma after radiotherapy for breast cancer have been treated between 1983 and 1997 at Henri Mondor University Hospital (France). Eight of these patients respected the criteria established by Cahan et al. The others had Stewart-Treves Syndrome and were thus excluded from the analysis. Only one of the eight patients had received chemotherapy. All of the patients at the time of diagnosis of radiation-induced sarcoma were free of breast cancer recurrence. Radiation-induced sarcoma appeared with a latency period of 5 to 18 years (mean: 10.3 years). Patients' ages ranged from 39 to 88 years (mean: 57.6 years) at the time of diagnosis of sarcoma. Three sarcomas occurred in the treated breast, two in the chest wall, one in the preclavicular area and two in the axillary region. There were two angiosarcomas, three fibrosarcomas, one osteosarcoma, one malignant fibrous histiocytoma (MFH), and one undifferentiated sarcoma. All patients have received treatment for their sarcoma: all of them underwent surgery, one patient combined radiotherapy and chemotherapy, and three patients chemotherapy.

RESULTS

Two patients were alive and free from disease. Six patients died (5-34 months); all six had local and/or metastatic recurrence.

CONCLUSIONS

Radiotherapy can induce malignancies after a latent period of several years. Radiation-induced sarcomas are associated with poor overall prognosis. The treatment in most of the cases is late and ineffective, therefore careful follow-up is needed. There are still many uncertainties and questions about radiation-induced sarcomas.

Postsurgical changes of the breast that mimic inflammatory breast carcinoma

OBJECTIVE

To characterize a clinical syndrome that occurs in some women who have undergone breast or axillary lymph node biopsy or partial mastectomy.

MATERIAL AND METHODS

Six case reports are presented, the clinical and histopathologic findings are described, and the implications for recognition of this entity are discussed.

RESULTS

Patients who had undergone partial mastectomy, breast biopsy, or axillary lymph node excision shortly thereafter had clinical signs (most notably, erythema and edema) suggestive of infectious mastitis or inflammatory breast cancer. Representative histologic sections of involved skin revealed dilated dermal vessels without specific evidence of infection or cancer. Although antibiotic therapy was generally ineffective, the clinical findings resolved with time (from 2 months to 1 year). This condition should be considered in the differential diagnosis when this circumscribed patient population has such intervention-related symptoms.

CONCLUSION

This clinical syndrome may mimic an infectious or neoplastic process, but we hypothesize that it is due to interruption of lymphatic vessels. Appropriate recognition may alter the use of antibiotic therapy or surgical intervention.

Dose and volume effects on fibrosis after breast conservation therapy

PURPOSE

To analyze factors involved in the development of fibrosis in the boost area after breast conservation therapy (BCT) in patients treated with continuous low dose rate iridium implants following 50 Gy whole breast irradiation.

METHODS AND MATERIALS

Fibrosis was estimated by palpation in 404 patients by four physicians. The median follow-up (FUP) duration was 70 months (range 30-133 months). Original implant data were used for reconstruction and dose-volume calculations. The total dose of the external whole breast irradiation and iridium implants was expressed in Normalized Total Dose (NTD): the total dose given in fractions of 2 Gy, which is biologically equivalent to the actual dose given according to the linear-quadratic model, using an alpha/beta value of 2 Gy, and 1.5 h for the recovery half-life of sublethal damage repair. To identify predictors of fibrosis we used a proportional odds model in a polychotomous logistic regression analysis.

RESULTS

Seven independent factors were identified that were related to the severity of fibrosis: age, duration of FUP, clinical T-size, photon beam energy, NTD level, implant volume, and adjuvant chemotherapy. From the proportional odds model, a volume exponent could be estimated (0.16 +/- 0.04) that enabled us to determine dose-effect relations for different volumes. A 10-fold higher risk of fibrosis was seen when the total dose was above 79 Gy as compared with doses lower than 70 Gy. A fourfold increase in risk of fibrosis was seen for each 100 cm3 increase in irradiated boost volume. The use of adjuvant chemotherapy resulted in a twofold increase in the risk of fibrosis (dose modifying factor approximately 1.08). The application of Co-60 beams had a similar effect. The relative odds for the other factors were smaller (1.4 for each 10 years of older age, and 1.2 for clinical T-size over 20 mm). The FUP-period had a nonlinear effect: relative odds 2.2 at 6 years, 3.6 at 7-8 years, and 2.8 at 9-11 years. The dose rate (mean 0.57, range 0.26-0.89 Gy/h) had no influence on the development of fibrosis and there was no correlation between dose rate and irradiated volume.

CONCLUSIONS

To optimize cosmetic results after BCT, both the total dose and the irradiated volume should be kept as low as possible. Minimum effective dose levels still have to be established. The boost volume can be minimized by more conformal brachytherapy techniques and optimal localization. It may be worthwhile to take adjuvant chemotherapy into account in decisions on boost dose levels.