Incidence of arm swelling following axillary clearance for breast cancer

Analysis of Spinal Dysfunction in Breast Cancer Survivors with Lymphedema

Background:

To study and analyse the spinal dysfunction in breast cancer survivors with lymphedema.

Methods:

This study was carried out by analysing total 116 breast cancer survivor women, who were having lymphedema. Out of 116 subjects, 39 undergone radical mastectomy (RM), 39 undergone modified radical mastectomy (MRM) and 38 undergone breast conserving surgery (BCS). Thesesubjects were assessed for spinal function bytaking range of motionusing goniometer, lymphedema measurement usinginch tape, spinal stability test and functional rating index.

Results:

The spinal range of motion wassignificantly reduced in patients suffering from lymphedema in breast cancer survivors. The strength and endurance were significantly reduced in abdominals, extensors and lateral muscles of spine. There wasmarked effect seen on quality of life of patients assessed by using functional rating index due to spinal dysfunction in lymphedema patients.

Conclusion:

This study showed that there is statistically significant spinal dysfunction caused due to lymphedema in breast cancer survivors.

Moxibustion as a Therapy for Breast Cancer-Related Lymphedema in Female Adults: A Preliminary Randomized Controlled Trial

Objective: To evaluate the effect of moxibustion on relieving breast cancer-related lymphedema. Materials and Methods: A randomized controlled trial was conducted in our institution from March 2016 to March 2017. All patients (N = 48) with cancer-related lymphedema were allocated to 2 groups: a treatment group, in which moxibustion was performed, and a control group, in which pneumatic circulation was performed with compression garments worn every day. Therapeutic efficacy was evaluated by measuring arm circumference (wrist crease, 10 cm proximal to wrist crease, elbow crease, and 10 cm proximal to elbow crease) and determining the Revised Piper Fatigue Scale score and Visual Analog Scale score for swelling before and after treatment. Results: All patients were treated for 4 consecutive weeks. Compared with 0 week after treatment, the affected-side arm circumference after 4 weeks' treatment decreased in both treatment and control groups; the difference value in the treatment group was superior to that in the control group. Compared with the controls, moxibustion resulted in a lower Visual Analog Scale score. The Revised Piper Fatigue total scores were improved in both the moxibustion and control group, and there was no significant difference between the 2 groups. Moxibustion reduced the behavioral, sensory, emotional, and cognitive Revised Piper Fatigue scores, but only the behavioral and sensory scores improved in the control group. Conclusion: Moxibustion has potential effect on breast cancer-related lymphedema. We present promising preliminary data for larger randomized trials to enable accurate evaluation of moxibustion as a lymphedema treatment.

Distance of Tumor to Skin as a Predictive Marker for Axillary Lymph Node Metastasis in Cases of Breast Carcinoma - A Retrospective Study

Background: Breast cancer is arising as the most common cancer among women. Axillary lymph node status is considered as one of the most important predictors of survival in breast cancer and a very important component to the staging system. The tumors under the skin have abundant access to the dermal lymphatic and have an increased chance of metastasizing to draining lymph nodes. Aim of the Study: To evaluate whether distance of tumor to skin can be considered as a predictor for lymph node metastasis. Materials and Methods: This was a retrospective study on all operated cases of infiltrating mammary carcinoma from January 2013 to December 2016. Both lumpectomy and mastectomy specimens with invasive carcinoma component were included in the study. The distance of the tumor was measured from the base of the epidermis of the skin to the anterior margin of the tumor on gross examination or microscopically the closest invasive carcinoma component. The distance was measured, tabulated, and correlated with the nodal status on axillary node dissection. Also, compared are the other parameters such as size, site, and grade of the tumor. Results:: Out of 200 patients enrolled, positive nodes were seen in 67.5% (135) of cases, of which tumor with distance from skin <0.3 cm show maximum nodal positivity (64.4%) and maximum cases with N2 and N3 disease (48.8%). Most important and significant finding was that 100% cases with tumor size corresponding in T2 size with skin invasion either grossly or microscopically and T3 size tumor with microscopically involving epidermis was positive for metastatic deposits in axillary nodes and 10/11 cases (90%) in T4 stage were positive. Conclusion: The distance of tumor from skin is an important predictor for Axillary lymph nodal metastasis in invasive breast cancers. Closer the tumor, the incidence of axillary nodal metastasis increases. Hence, distance of tumor from skin should be considered while evaluating a breast cancer patient.

Study of Sentinel Lymph Node in Breast Cancer: Our Experience in 46 Cases

At the Surgery Department of Biella 46 patients were enrolled in a study on the sentinel lymph node (SN) in the period from 1 January 1999 to 30 September 1999. The aim of the study was to determine, on the basis of our own experience, the percentages of accuracy and concordance, and compare them with case series abroad and in Italy; in addition, we sought to establish a possible correlation between certain features of breast cancer and positivity of the axilla. The method utilized was lymphoscintigraphy and gamma probe. Fifteen cases with positive axillary lymph nodes and 12 cases with positive sentinel lymph nodes were found; there were no false positive and three false negative results. No migration of the tracer was observed with lymphoscintigraphy in two cases. The percentage of concordance obtained was 93.2% in the complete series and 96.5% in the subseries that excluded the learning curve. Comparing the percentage of concordance of our case series with those abroad and in Italy, an average overlapping percentage was obtained. The percentage of accuracy obtained in our study was 95.7%, which is slightly higher than the average of percentages of the case series abroad and in Italy.

Unilateral upper extremity lymphedema deteriorates the postural stability in breast cancer survivors

Aim of the study

There is little known about any change in postural balance caused by asymmetrical volume increase due to unilateral upper extremity lymphedema in patients who underwent breast surgery. The aim of this study was to determine whether there is a change in postural balance by measuring postural sway velocity (PSV), center of gravity (CoG) displacement and directional control (DCL) in patients with unilateral upper extremity lymphedema in breast cancer survivors.

Material and methods

Eighteen females 38–60 (M = 53) years old diagnosed with upper extremity lymphedema due to breast cancer surgery, and 18 healthy females with similar ages (M = 52.5) were assessed using the Balance Master system (Neuro Com, Clackamas, USA). Unilateral stance (US) and bilateral stance (BS) tests in eyes open and closed conditions and the limit of stability (LOS) test were applied to quantify postural sway velocity (PSV), CoG displacement, and directional control (DCL).

Results

The lymphedema group showed a significant increase in PSV in the US test on the ipsilateral leg with eyes open (p = 0.02) and eyes closed (p = 0.005) as well as on the contralateral leg with eyes open (p = 0.004) and eyes closed (p = 0.0001). Average displacement and position of the CoG were 25% of LOS (p = 0.0001) towards the lymphedema side and 60.6 degrees respectively. DCL in the lymphedema group was significantly lower in forward (p = 0.0001), back (p = 0.003), ipsilateral (p = 0.002), and contralateral (p = 0.03) directions.

Conclusions

These findings suggest that unilateral upper extremity lymphedema may have challenging effects on postural balance.

miRNA expression in breast cancer varies with lymph node metastasis and other clinicopathologic features

Breast carcinoma is the most common malignant tumor in females, and lymph node (LN) status is one of the most important prognostic factors in patients with breast cancer. MiRNAs have been shown to have important role in oncogenesis, invasion, and metastasis via epigenetic post-transcriptional gene regulation. However, lymphatic metastasis-related miRNAs of breast cancer has not been well documented. The aim of this study was to identify and evaluate miRNAs related to breast cancer LN metastasis and to explore the clinical significance of the differentially expressed miRNAs in patients with breast cancer. The expression of miRNAs in patients with primary breast cancer with LN metastasis and that without LN metastases was compared by miRNA microarray. We further validated the miRNAs (miR-185-5p, miR-339-5p, miR-542-5p, and miR-3923) between LN (n = 31) and nonlymph node (NLN; n = 42) group using real-time reverse transcriptase polymerase chain reaction. Furthermore, the relationship between miRNA expression and clinical pathological features was analyzed. The miRNA microarray initially identified that eight miRNAs (miR-206, miR-3923, miR-181a, miR-92a, miR-421, miR-339-5p, miR-3196, and miR-29b) were downregulated in LN metastasis group, whereas five miRNAs (miR-542-5p, miR-200a, miR-564, miR-451, miR-30c, miR-200b, miR-191-3p, miR-142-5p, and miR-185-5p) were upregulated in LN group when compared with those in NLN group. In the validation cohort, the expression levels of miR-185-5p and miR-542-5p were significantly expressed higher in LN group (P = 0.002 and P = 0.001, respectively), and the expression levels of miR-339-5p and miR-3923 were significantly expressed lower in LN group (P = 0.001 and P = 0.001, respectively). Our results indicate the potential role of miR-185-5p, miR-542-5p, miR-339-5p, and miR-3923 in predicting metastasis to the LN and prognosis in breast cancers.

Axillary ultrasonography in breast cancer patients helps in identifying patients preoperatively with limited disease of the axilla

BACKGROUND

The sentinel lymph node biopsy (SLNB) procedure is the method of choice for the identification and monitoring of regional lymph node metastases in patients with breast cancer. In the case of a positive sentinel lymph node (SLN), additional lymph node dissection is still warranted for regional control, although 40-65 % have no additional axillary disease. Recent studies show that after breast-conserving surgery, SLNB, and adjuvant systemic therapy, there is no significant difference between recurrence-free period and overall survival if there are ≤2 positive axillary nodes. The purpose of this study was preoperative identification of patients with limited axillary disease (≤2 macrometastases) by using ultrasonography.

METHODS

Data from 1,103 consecutive primary breast cancer patients with tumors smaller than 50 mm, no palpable adenopathy, and a maximum of 2 SLNs with macrometastases were collected. The variable of interest was US of the axilla.

RESULTS

Of the 1,103 patients included, 1,060 remained after exclusion criteria. Of these, 102 (9.6 %) had more than 2 positive axillary nodes on ALND. Selected by unsuspected US, the chance of having >2 positive lymph nodes (LNs) is substantially lower (4.2 %). This is significant on univariate and multivariate analysis. After excluding the patients with extracapsular extension of the SLN, the chance of having >2 positive LNs is only 2.6 %. For pT1-2, this is 2.2 %.

CONCLUSIONS

The risk of more than 2 positive axillary nodes is relatively small in patients with cT1-2 breast cancer. US of the axilla helps in further identifying patients with a minimal risk of additional axillary disease, putting ALND up for discussion.

Lymphatic complications in surgery: possibility of prevention and therapeutic options

The problem of prevention of lymphatic complications in surgery is extremely important if we think about the frequency of both early complications such as lymphorrhea, lymphocele, wound dehiscence and infections and late complications such as lymphangitis and lymphedema. Nowadays, it is possible to identify risk patients and prevent these lesions or treat them at an early stage. This report helps to demonstrate how it is important to integrate diagnostic and clinical findings to better understand how to properly identify risk patients for lymphatic injuries and, therefore, when it is useful and proper to do prevention. Authors report their experiences in the prevention and treatment of lymphatic injuries after surgical operations and trauma. After an accurate diagnostic approach, prevention is based on different technical procedures among which microsurgical procedures. It is very important to follow-up the patient not only clinically but also by lymphoscintigraphy. A protocol of prevention of secondary limb lymphedema was proposed and it includes, from the diagnostic point of view, lymphoscintigraphy and, as concerns therapy, it recognizes also a role to early microsurgery. It is necessary to accurately follow-up the patient who has undergone an operation at risk for the appearance of lymphatic complications and, even better, to assess clinically and by lymphoscintigraphy the patient before surgical operation.

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.

Prevention of lymphatic injuries in surgery

BACKGROUND

The problem of prevention of lymphatic injuries in surgery is extremely important if we think about the frequency of both early complications such as lymphorrhea, lymphocele, wound dehiscence, and infections and late complications such as lymphangites and lymphedema. Nowadays, it is possible to identify risk patients and prevent these lesions or treat them at an early stage. This article helps to demonstrate how it is important to integrate diagnostic and clinical findings to better understand how to properly identify risk patients for lymphatic injuries and, therefore, when it is useful and proper to do prevention.

METHODS

Authors report their experiences in the prevention and treatment of lymphatic injuries after surgical operations and trauma. After an accurate diagnostic approach, prevention is based on different technical procedures among which microsurgical procedures. It is very important to follow-up the patient not only clinically but also by lymphoscintigraphy.

RESULTS AND CONCLUSIONS

It was identified a protocol of prevention of secondary limb lymphedema that included, from the diagnostic point of view, lymphoscintigraphy and, as concerns therapy, it also recognized a role to early microsurgery. It is necessary to accurately follow-up the patient who has undergone an operation at risk for the appearance of lymphatic complications and, even better, to assess clinically and by lymphoscintigraphy the patient before surgical operation.

Longitudinal change of treatment-related upper limb dysfunction and its impact on late dysfunction in breast cancer survivors: a prospective cohort study

BACKGROUND AND OBJECTIVES

To investigate the prevalence of upper limb dysfunction (ULD) and subtypes after breast cancer surgery and to identify factors associated with late ULD.

METHODS

Among 191 enrolled patients, 191 were evaluated at 3 months, 187 at 6 months, and 183 at 12 months after surgery. Pain, shoulder range of motion, muscle strength, and arm circumference were assessed. Based on symptoms and physical examinations, the types of ULD common after breast cancer treatment were diagnosed and categorized.

RESULTS

The prevalence of ULD after surgery were 24.6%, 20.9%, and 26.8% at 3, 6, and 12 months, respectively. The most common types of ULD were pectoralis tightness at 3 and 6 months and lymphedema at 12 months. Patients with pectoralis tightness or lymphedema at 3 or 6 months showed a higher prevalence of rotator cuff disease at 12 months compared with those without early pectoralis tightness or lymphedema.

CONCLUSIONS

The major post-operative ULD were pectoralis tightness at 3 and 6 months and lymphedema at 12 months. Late ULD such as rotator cuff disease were associated with pectoral tightness or lymphedema at earlier stages. Diagnosis and treatment of ULD should take place as soon as possible after surgery.

Clinicopathological factors and nomograms predicting nonsentinel lymph node metastases after neoadjuvant chemotherapy in breast cancer patients

BACKGROUND

Studies have demonstrated the feasibility and accuracy of sentinel lymph node (SLN) biopsy after neoadjuvant chemotherapy (NAC) in breast cancer. Some SLN-positive patients have low risk of nonsentinel lymph node (non-SLN) involvement. Our goal was to determine clinicopathological factors correlating with the presence of non-SLN metastases in patients after NAC and to assess the validity of nomograms predicting additional axillary metastases.

METHODS

Patients with infiltrating breast carcinoma (n = 132) were studied prospectively. All patients received NAC. At surgery, SLN biopsy followed by axillary lymph node dissection was performed. Lymphatic mapping was done using the isotope method. Fifty-one patients were SLN positive.

RESULTS

In univariate analysis, tumor size (P = 0.016) and the size of SLN metastases (P = 0.0055) were significantly correlated with the presence of non-SLN metastases. In multivariate analysis, SLN macrometastases (P = 0.047) conferred significantly increased risk of non-SLN metastases. The Memorial Sloan-Kettering Cancer Center nomogram was not reliably predictive for non-SLN metastases (area under the receiver operating characteristic curve, AUC, of 0.542), whereas the MD Anderson (AUC 0.716) and Tenon scoring systems (AUC 0.778) were validated.

CONCLUSION

Our results suggest that clinicopathological factors predicting non-SLN involvement in SLN-positive patients with and without NAC are essentially the same. The risk of involvement may be assessed using existing nomograms, but additional large prospective studies are needed to determine their accuracy in patients after NAC.

Lymphedema and quality of life in Chinese women after treatment for breast cancer

AIMS

To determine the magnitude of arm symptom-associated distress and quality of life in patients suffering from lymphedema after axillary dissection for breast cancer.

DESIGN AND METHODS

Two hundred and two breast cancer patients were interviewed, including 101 lymphedema cases and 101 controls who were matched in terms of surgery date, axillary radiotherapy and cancer stage. The FACT-B+4 quality-of-life instrument was used to assess breast, emotional, functional, physical, and social well-being. A self-devised Arm Symptom Distress scale was used to collect information about arm morbidities including swelling, pain, numbness or tingling, limitation of movement, infection; and their interference on daily life. Arm circumference at different levels was measured to determine the presence and severity of lymphedema. The association between lymphedema and quality of life was evaluated, controlling for patient demographics and clinical factors.

RESULTS

Compared with controls, individuals with lymphedema had a significantly worse score on FACT-B+4 and the Arm Symptom Distress scale. The score was significantly lower in five of the six domains of FACT-B+4, and significantly higher in both subscales of the Arm Symptom Distress scale. Patients with severe lymphedema had a significantly worse Symptom Severity sub-score on the Arm Symptom Distress scale than those with mild lymphedema.

CONCLUSIONS

Among women who have undergone axillary dissection for breast cancer, lymphedema was associated with an inferior quality of life and a higher level of arm symptom-associated distress. Patients with severe lymphedema had more arm symptom-associated distress than those with mild lymphedema.

Sentinel lymphnode biopsy in early breast cancer using methylene blue dye and radioactive sulphur colloid - a single institution Indian experience

BACKGROUND

Axillary lymph node dissection is an established procedure in breast cancer staging. However, it is associated with unpleasant side effects. A promising alternative to assess axillary lymph node status in early breast cancer patients is Sentinel Lymph Node Biopsy (SLNB). Isosulfan blue has traditionally been the dye used to identify the Sentinel Lymph Node (SLN). This article is a validation study of SLNB using methylene blue dye and radioactive sulphur colloid in early breast cancer Indian patients. MATERIALS #ENTITYSTARTX00026;

METHODS

With written informed consent, 100 patients with cytology or biospy proven carcinoma breast, clinical stage T1/ T2 N0 M0, underwent SLNB using combination of methylene blue dye & radioactive technetium 99m sulphur colloid as a part of validation study from June 2003 to February 2006. After validation study, from March 2006 to February 2007, 35 patients have undergone SLNB followed by complete axillary clearance in only those patients with SLNB being positive for metastases.

RESULTS

In all 100 patients of the validation study SLN was identified. Total number of cases with positive axillary nodes was 27, out of which SLN was only positive node for metastases in 69% of cases. The overall sensitivity, specificity, positive predictive valve and negative predictive valve of SLNB 96.2%, 100%, 100% and 98.6% respectively with false negative rate of 3.7%. In subsequent 35 patients who underwent SLNB followed by complete axillary clearance, SLNs was identified in all the cases.

CONCLUSIONS

SLNB is effective in early breast cancer patients of Indian population. SLNB using combination of methylene blue dye and radio-active Tc99m sulphur colloid can stage the axilla with high accuracy & low risk of false negativity in early breast cancer patients.

Prevalence of teaching sentinel lymph node biopsy for breast cancer in general surgery residency programs

PURPOSE

Sentinel lymphadenectomy (SLNB) for the evaluation of clinically negative lymph nodes in women with invasive breast cancer is rapidly gaining acceptance within the surgical community. The purpose of this study was to document the prevalence of teaching SLNB to residents in general surgery training programs in the United States.

METHODS

The Fellowship and Residency Electronic Interactive Database (FREIDA) was searched for a listing of all general surgery residency programs. A short questionnaire was mailed to the program director of each residency program listed. The program directors were asked whether general surgery residents are taught the technique of performing SLNB for breast cancer, and how the procedure is performed at their institutions.

RESULTS

Of the 255 surgical programs listed in FREIDA, 191 or 75% responded to the survey. Of responding programs, 92% are currently teaching surgical residents SLNB, whereas 4% plan on adding SLNB to the curriculum within the next academic year. A total of 74% of programs are performing SLNB as part of an organized hospital protocol, whereas 40% routinely follow SLNB with an axillary node dissection. A total of 89% of the programs use both sulfur colloid radioisotope and isosulfan blue dye, whereas 7% use dye alone, and 4% use only radioisotope.

CONCLUSIONS

The practice of performing SLNB for the purpose of detecting occult nodal metastases in breast cancer is being taught at most surgery training programs in this country. In the less than 6 years since the modification of this technique for the treatment of breast disease, it has become the standard of care for treating women with invasive breast cancer with clinically negative axillary lymph nodes at training hospitals in the United States.

Measurement of limb volume: laser scanning versus volume displacement

BACKGROUND

Determining the prevalence and treatment success of surgical lymphedema requires accurate and reproducible measurement. A new method of measurement of limb volume is described.

METHODS

A series of inanimate objects of known and unknown volume was measured using digital laser scanning and water displacement. A similar comparison was made with 10 human volunteers. Digital scanning was evaluated by comparison to the established method of water displacement, then to itself to determine reproducibility of measurement.

RESULTS

(1) Objects of known volume: Laser scanning accurately measured the calculated volume but water displacement became less accurate as the size of the object increased. (2) Objects of unknown volume: As average volume increased, there was an increasing bias of underestimation of volume by the water displacement method. The coefficient of reproducibility of water displacement was 83.44 ml. In contrast, the reproducibility of the digital scanning method was 19.0 ml. (3) Human data: The mean difference between water displacement volume and laser scanning volume was 151.7 ml (SD +/- 189.5). The coefficient of reproducibility of water displacement was 450.8 ml whereas for laser scanning it was 174 ml.

CONCLUSION

Laser scanning is an innovative method of measuring tissue volume that combines precision and reproducibility and may have clinical utility for measuring lymphedema.

Morbidity of sentinel lymph node biopsy (SLN) alone versus SLN and completion axillary lymph node dissection after breast cancer surgery: a prospective Swiss multicenter study on 659 patients

OBJECTIVE

To assess the morbidity after sentinel lymph node (SLN) biopsy compared with SLN and completion level I and II axillary lymph node dissection (ALND) in a prospective multicenter study.

SUMMARY BACKGROUND DATA

ALND after breast cancer surgery is associated with considerable morbidity. We hypothesized: 1) that the morbidity in patients undergoing SLN biopsy only is significantly lower compared with those after SLN and completion ALND level I and II; and 2) that SLN biopsy can be performed with similar intermediate term morbidity in academic and nonacademic centers.

METHODS

Patients with early stage breast cancer (pT1 and pT2 <or= 3 cm, cN0) were included between January 2000 and December 2003 in this prospective Swiss multicenter study. All patients underwent SLN biopsy. In all patients with SLN macrometastases and most patients with SLN micrometastases (43 of 68) or isolated tumor cells (11 of 19), a completion ALND was performed. Postoperative morbidity was assessed based on a standardized protocol.

RESULTS

SLN biopsy alone was performed in 449 patients, whereas 210 patients underwent SLN and completion ALND. The median follow-ups were 31.0 and 29.5 months for the SLN and SLN and completion ALND groups, respectively. Intermediate-term follow-up information was available from 635 of 659 patients (96.4%) of enrolled patients. The following results were found in the SLN versus SLN and completion ALND group: presence of lymphedema (3.5% vs. 19.1%, P < 0.0001), impaired shoulder range of motion (3.5% vs. 11.3%, P < 0.0001), shoulder/arm pain (8.1% vs. 21.1%, P < 0.0001), and numbness (10.9% vs. 37.7%, P < 0.0001). No significant differences regarding postoperative morbidity after SLN biopsy were noticed between academic and nonacademic hospitals (P = 0.921).

CONCLUSIONS

The morbidity after SLN biopsy alone is not negligible but significantly lower compared with level I and II ALND. SLN biopsy can be performed with similar short- and intermediate-term morbidity in academic and nonacademic centers.

Lymphedema following axillary lymph node dissection for breast cancer

Lymphedema is a relatively common, potentially serious and unpleased complication after axillary lymph node dissection (ALND) for breast cancer. It may be associated with functional, esthetic, and psychological problems, thereby affecting the quality-of-life (QOL) of breast cancer survivors. Objective measurements (preferentially by measuring arm volumes or arm circumferences at predetermined sites) are required to identify lymphedema, but also subjective assessment can help to determine the clinical significance of any volume/circumference differences. Lymphedema per se predisposes to the development of other secondary complications, such as infections of the upper limb, psychological sequelae, development of malignant tumors, alterations of the QOL, etc. The risk of lymphedema is associated with the extent of ALND and the addition of axillary radiation therapy. Treatment involves the application of therapeutic measures of the so-called decongestive lymphatic therapy. Prevention is of key importance to avoid lymphedema formation. The application of the sentinel lymph node biopsy in the management of breast cancer has been associated with a reduced incidence of lymphedema formation.

Supraclavicular radiotherapy must be limited laterally by the coracoid to avoid significant adjuvant breast nodal radiotherapy lymphoedema risk

This cross-sectional study aimed to investigate the effect of supraclavicular fossa (SCF) radiotherapy volumes as well as patient characteristics and nodal pathology on the development of lymphoedema. Ninety-one women who had received SCF nodal radiotherapy after axillary dissection were evaluated. Lymphoedema was defined by two measurements: limb volume difference 200 mL, or circumference difference 10 cm proximal or distal to the olecranon>2 cm. On univariate analysis, the addition of axillary to SCF radiotherapy, increasing width of the SCF field, increasing age, presence of extracapsular extension of nodal involvement and use of hormone treatment was associated with lymphoedema by either one or both definitions. For both definitions of lymphoedema, on multivariate analysis, increasing nodal radiotherapy volume remained significant (P=0.02 to 0.007), as did increased age (P=0.05 to 0.001). We conclude that conventionally fractionated SCF radiotherapy limited laterally by the coracoid process has a lymphoedema risk similar to that expected from axillary dissection alone and a lower risk than wider SCF fields with or without an axillary boost.

Impact of sentinel lymph node biopsy on the evolution of breast reconstruction

BACKGROUND

Although sentinel lymph node biopsy is rapidly replacing complete axillary lymph node dissection for lymph node staging in women with clinically node-negative breast cancer, it is unclear what impact the transition to sentinel lymph node biopsy will have on the practice of breast reconstruction.

METHODS

To determine the effect of the transition from complete axillary lymph node dissection to sentinel lymph node biopsy on their practice of breast reconstruction, the authors reviewed the records of 717 patients with breast cancer who underwent sentinel lymph node biopsy and 1887 breast reconstructions-487 were performed in patients who also underwent sentinel lymph node biopsy at The University of Texas M. D. Anderson Cancer Center between 1998 and 2003.

RESULTS

Before 1999, sentinel lymph node biopsy was performed infrequently. Between 1999 and 2003, the number of sentinel lymph node biopsy procedures performed per year increased almost 50-fold. Concurrent with this increase in the use of sentinel lymph node biopsy, there was a corresponding increase in the proportion of breast reconstruction procedures performed in patients who had also undergone sentinel lymph node biopsy (13 percent per year, p = 0.0001). In 2003, 54 percent of all breast reconstructions were performed in patients who had sentinel lymph node biopsy. In 2000, 1 year after the use of sentinel lymph node biopsy began to increase, the choice of recipient vessels for free transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction began to change. Between 2001 and 2002, the internal mammary vessels replaced the thoracodorsal vessels as the preferred recipient vessels for TRAM flap reconstruction (p < 0.0001). Over the study period, the authors noted a decrease in the percentage of free TRAM flap procedures requiring revision, more frequent use of contralateral implant-based augmentation to achieve symmetry, an increase in the percentage of patients desiring a second attempt at reconstruction after loss of a TRAM flap, and a decrease in the percentage of patients being referred for physical therapy or treatment of lymphedema after free TRAM flap reconstruction.

CONCLUSIONS

The transition from axillary lymph node dissection to sentinel lymph node biopsy has resulted in a change in breast reconstruction practices. The increased use of the internal mammary vessels reflects the decreased dissection of axillary tissue to expose the thoracodorsal vessels with sentinel lymph node biopsy in addition to concern that a subsequent axillary surgery to remove additional axillary nodes might injure the thoracodorsal vessels should they be used in breast reconstruction. Awareness of the decreased morbidity associated with sentinel lymph node biopsy has led patients to expect less morbidity and better aesthetic outcomes from TRAM flap reconstruction.

Risks and benefits of needle use in patients after axillary node surgery

Lymphoedema may be triggered by any type of injection. This is not just an issue for the cured breast cancer patient but for any patient who has undergone under-arm (axillary) lymph node removal to any degree for any type of cancer. Standard advice given to patients following axillary node removal is to avoid any injection or blood pressure measurement on the ipsilateral arm. The evidence base in this area is severely lacking. Patients have reported frustration that nurses are not informed of contraindications in carrying out such procedures on patients at risk of developing swelling. This article discusses the current evidence available on the subject of non-accidental skin puncture (NASP) relating to the patient at risk of lymphoedema and provides guidelines for any professionals conducting such procedures for patients with a history of cancer. The results from a small audit of the guidelines are cited and they reveal that out of 14 patients who underwent NASP procedures in the at risk arm, no patients reported swelling to that limb within a month of these procedures.

Comparative study of lymphoedema with axillary node dissection versus axillary node sampling with radiotherapy in patients undergoing breast conservation surgery

AIMS

Our aim was to compare the incidence of lymphoedema in two groups of patients undergoing breast conservation surgery; one undergoing axillary sampling and radiotherapy to patients with positive axillary nodes, and the other undergoing axillary clearance.

METHODS

Retrospective review of records of two sequential groups of patients; one undergoing axillary sampling between January 1994 and December 1998 (Group 1) and the other undergoing axillary clearance between January 2000 and December 2002 (Group 2). Both groups had minimum of 2 years follow-up.

RESULTS

Three hundred and twelve patients were included in Group 1 and 194 in Group 2. 2.2% of the patients in Group 1 developed lymphoedema compared to 12.3% in Group 2. This was statistically significant with a P value=0.0001. In the node-positive patients, the incidence of lymphoedema in Group 1 was 6.2% compared to 15.4% in Group 2, although the differences were not statistically significant with P=0.17.

CONCLUSIONS

The incidence of lymphoedema in the axillary sampling group was low, although the differences were less pronounced in the node-positive patients. The effectiveness of radiotherapy as an alternative to full axillary dissection among patients with positive nodes is currently under investigation in randomised controlled trials.

Low-level laser therapy in management of postmastectomy lymphedema

The aim of this paper was to study the effects of low-level laser therapy (LLLT) in the treatment of postmastectomy lymphedema. Eleven women with unilateral postmastectomy lymphedema were enrolled in a double-blind controlled trial. Patients were randomly assigned to laser and sham groups and received laser or placebo irradiation (Ga-As laser device with a wavelength of 890 nm and fluence of 1.5 J/cm2) over the arm and axillary areas. Changes in patients' limb circumference, pain score, range of motion, heaviness of the affected limb, and desire to continue the treatment were measured before the treatment and at follow-up sessions (weeks 3, 9, 12, 18, and 22) and were compared to pretreatment values. Results showed that of the 11 enrolled patients, eight completed the treatment sessions. Reduction in limb circumference was detected in both groups, although it was more pronounced in the laser group up to the end of 22nd week. Desire to continue treatment at each session and baseline score in the laser group was greater than in the sham group in all sessions. Pain reduction in the laser group was more than in the sham group except for the weeks 3 and 9. No substantial differences were seen in other two parameters between the two treatment groups. In conclusion, despite our encouraging results, further studies of the effects of LLLT in management of postmastectomy lymphedema should be undertaken to determine the optimal physiological and physical parameters to obtain the most effective clinical response.

An axilla scoring system to predict non-sentinel lymph node status in breast cancer patients with sentinel lymph node involvement

BACKGROUND

Axillary lymph node dissection (ALND) is the current standard of care for breast cancer patients with sentinel lymph node (SN) involvement. However, the SN is the only involved axillary node in a significant proportion of these patients. Here we examined factors predictive of non-SN involvement in patients with a metastatic SN, in order to develop a scoring system for predicting non-SN involvement.

MATERIALS AND METHODS

This study was based on a prospective database of 337 patients who underwent SN biopsy for breast cancer, of whom 81 (24%) were SN-positive; we examined factors predictive of non SN involvement in the 71 of these 81 women who underwent complementary ALND. All clinical and histological criteria were recorded and analysed according to non-SN status, by using Chi-2 analysis, Student's t-test, and multivariate logistic regression.

RESULTS

Univariate analysis showed a significant association between non-SN involvement and histological primary tumor size (p=0.0001), SN macrometastasis (p=0.01), the method used to detect SN metastasis (H&E versus immunohistochemistry) (p=0.03), the number of positive SNs (p=0.049), the proportion of involved SNs among all identified SNs (p=0.0001) and lymphovascular invasion (p=0.006). Histological primary tumor size (p=0.006), SN macrometastasis (p=0.02) and the proportion of involved SNs among all identified SNs (p=0.03) remained significantly associated with non-SN status in multivariate analysis. Based on the multivariate analysis, we developed an axilla scoring system (range 0-7) to predict the likelihood of non-SN metastasis in breast cancer patients with SN involvement.

CONCLUSION

In patients with invasive breast cancer and a positive SN, histological primary tumor size, the size of SN metastases, and the proportion of involved SNs among all identified SNs were independently predictive of non-SN involvement.

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.

Massage therapy in the treatment of lymphedema

The ongoing NCCAM-supported experimental and clinical translational approaches should shed light not only on the physiologic mechanisms underlying the benefits of massage therapy but could also, if successful in defined populations of patients, have a substantial impact by providing a simpler, more cost-effective LE treatment alternative worldwide.

Long-term outcomes of breast cancer patients after endoscopic axillary lymph node dissection: a prospective analysis of 52 patients

BACKGROUND

Reports on long-term outcomes after endoscopic axillary lymph node dissection (ALND) of breast cancer patients are still lacking in the medical literature. The objective of this prospective study was to assess the oncological and functional outcomes in breast cancer patients after endoscopic ALND.

METHODS

Fifty-five breast cancer patients were prospectively enrolled, of whom 52 were available for follow-up with a median of 71.9 months (range 11-96). The following oncological and functional endpoints were evaluated during follow-up at several time points: occurrence of local, axillary and distant metastases, seroma or infection, shoulder mobility (range of motion), numbness, pain, presence of lymphoedema as well as restriction in activities of daily living.

RESULTS

In 52 patients endoscopic ALND of level I and II was successfully performed. Two port-site metastases (2/52, 4%) occurred, one of which in a patient with negative axillary lymph nodes. The same patient suffered from the only axillary recurrence (1/52, 2%). Three patients (3/52, 6%) developed lymphoedema. No other functional adverse events (shoulder mobility, pain, numbness, hypertrophic scar) were noticed at the end of the observation period.

CONCLUSION

The present investigation with long-term follow-up after endoscopic ALND--the first one in the literature--reveals minor morbidity, good functional and cosmetic results. In contrary to conventional surgery, the endoscopic procedure is associated with the occurrence of port-site metastases, not seen in the open approach. Axillary recurrences do not appear more frequently when compared with results after conventional ALND. In the meantime the less invasive sentinel lymph node (SLN) biopsy is the established standard technique in evaluating the axillary lymph node status.

Lymphedema after complete axillary node dissection for melanoma: assessment using a new, objective definition

OBJECTIVES

The objectives of this study were to define appropriate criteria for assessing the presence of lymphedema, and to report the prevalence and risk factors for development of upper limb lymphedema after level I-III axillary dissection for melanoma.

SUMMARY BACKGROUND DATA

The lack of a consistent and reliable objective definition for lymphedema remains a significant barrier to appreciating its prevalence after axillary dissection for melanoma (or breast carcinoma).

METHODS

Lymphedema was assessed in 107 patients (82 male, 25 female) who had previously undergone complete level I-III axillary dissection. Of the 107 patients, 17 had also received postoperative axillary radiotherapy. Arm volume was measured using a water displacement technique. Change in volume of the arm on the side of the dissection was referenced to the volume of the other (control) arm. Volume measurements were corrected for the effect of handedness using corrections derived from a control group. Classification and regression tree (CART) analysis was used to determine a threshold fractional arm volume increase above which volume changes were considered to indicate lymphedema.

RESULTS

Based on the CART analysis results, lymphedema was defined as an increase in arm volume greater than 16% of the volume of the control arm. Using this definition, lymphedema prevalence for patients in the present study was 10% after complete level I-III axillary dissection for melanoma and 53% after additional axillary radiotherapy. Radiotherapy and wound complications were independent risk factors for the development of lymphedema.

CONCLUSIONS

A suggested objective definition for arm lymphedema after axillary dissection is an arm volume increase of greater than 16% of the volume of the control arm.

Sentinel lymph node biopsy in breast cancer

The sentinel lymph node (SLN) procedure consists of identifying the first lymph node to receive lymphatic vessels draining a tumour. Sentinel node biopsy is a minimally invasive technique, resulting in lower morbidity than traditional axillary lymph node dissection. Screen detected breast cancers are associated with approximately a 20% incidence of axillary node involvement. Sentinel node biopsy represents a minimally invasive method of accurately staging these patients.

Evaluation of immediate versus delayed shoulder exercises after breast cancer surgery including lymph node dissection--a randomised controlled trial

Two hundred and thirty women who had undergone surgery for breast cancer were randomised to a prospective study, comparing early (group A) and delayed (group B) shoulder exercise. Preoperatively, group A received instructions and an exercise programme supervised by a physiotherapist, whereas group B received written instructions to use the arm normally but to avoid heavy work. Two weeks after surgery both groups were given identical exercise programmes. Shoulder mobility, hand strength and arm volume were measured preoperatively, 1 month, 6 months and 2 years postoperatively. After 2 years 13.8% of the women had lymphoedema, but there were no significant differences between the groups. Grip strength was slightly decreased during the postoperative period in both groups (n.s.). Postoperatively, all movements in both groups were decreased after 2 weeks and 1 month and shoulder elevation and abduction remained decreased at 2 years. Mobility in group A recovered significantly earlier than in group B.

Lymphedema after treatment of breast cancer

BACKGROUND

Lymphedema is one of the major long-term complications of axillary dissection. This study was designed to investigate the risk factors that are predicted to effect the development of lymphedema after complete axillary dissection.

METHODS

Two hundred forty patients who had undergone modified radical mastectomy with complete axillary dissection were examined at least 18 months after the surgery. The effects of age, diabetes, smoking, hypertension, chemotherapy, radiotherapy, tamoxifen use, stage, body mass index, number of the removed and metastatic lymph nodes, and total volume of the wound drainage on the development of lymphedema were analyzed.

RESULTS

Lymphedema developed in 68 (28%) of the 240 cases. Axillary radiotherapy and body mass index were found to increase the incidence of the lymphedema.

CONCLUSIONS

Women who had the combination of full axillary dissection and axillary radiotherapy carry a significant risk of lymphedema.

Intraoperative imprint cytology of sentinel nodes in breast cancer

BACKGROUND AND OBJECTIVES

Sentinel node (SN) biopsy is a new standard of care for axillary node staging in patients with early-stage, clinically node-negative breast cancer. A second operation can be avoided when the results are available intraoperatively. However, there is no standard intraoperative method for SN assessment. The aim of this study was to evaluate intraoperative imprint cytology (IC) for the detection of SN involvement in patients with early-stage breast cancer.

METHODS

One hundred eighty-five consecutive patients with a breast tumor underwent SN biopsy with intraoperative IC. The SN was bisected and a touch preparation was made with a glass slide, on both sides of the cut. Permanent sections were evaluated with H&E and immunohistochemical staining. The IC results were compared with the final histologic results.

RESULTS

The sensitivity, specificity, accuracy, and positive and negative predictive values of IC were 33.3, 78.4, 78.9, 90, and 77.5%, respectively. IC was more sensitive for macrometastases than for micrometastases. In the 118 patients studied after the learning phase, 9 patients with a positive SN by IC avoided a second operation.

CONCLUSIONS

Intraoperative IC of SNs appears to be reasonably reliable in patients with breast cancer, permitting axillary dissection during the same surgical procedure when positive. In contrast, sensitivity for detection of micrometastases is low.

Predictive Factors for the Status of Non-sentinel Nodes in Breast Cancer Patients with Tumor Positive Sentinel Nodes

In patients with tumor positive sentinel nodes, axillary lymph node dissection is routinely performed while a majority of these patients have no tumor involvement in the non-sentinel nodes. The authors tried to identify a subgroup of patients with a tumor positive sentinel node without non-sentinel node tumor involvement. In 135 consecutive patients with tumor positive sentinel nodes and axillary lymph node dissection performed, the incidence of non-sentinel node involvement according to tumor and sentinel node related factors was examined. The size of the sentinel node metastasis, size of primary tumor and number of tumor positive sentinel nodes were the three factors significantly predicting the status of the non-sentinel nodes. The size of the sentinel node metastasis was the strongest predictive factor (P < 0.0001). In a subgroup of 41 patients with a stage T1 tumor and micrometastatic involvement in the sentinel node only 2 patients (5%) had non-sentinel node involvement. In patients with small primary tumors and micrometastatic involvement of the sentinel nodes, the chance of non-sentinel node involvement is small but cannot be discarded. Because the clinical relevance of micrometastases in lymph nodes is still unclear it is not advisable to omit axillary lymph node dissection even in these patients.

Arm edema after lumpectomy and breast irradiation

Ipsilateral arm edema can be a troublesome adverse sequel of breast conservation therapy. We carried out a prospective study of arm edema in every patient (265) seen during a 6-month period for follow-up after radiotherapy postlumpectomy for unilateral primary breast cancer. One hundred eighty-one (181) women (68.3%) had an axillary dissection. All had radiotherapy to the breast via parallel opposed tangential beams. Only eight (3%) had additional separate portals for irradiation of nodal areas. Adjuvant systemic therapy consisted of tamoxifen alone in 127 patients (47.9%) and chemotherapy with or without tamoxifen in 60 (22.6%). Ipsilateral arm edema developed in 19 patients (7.2%). Edema was mild (1+) in 16 patients, and moderate in 3 (2+). Multivariate analysis revealed that the risk of arm edema was significantly increased in heavier women (p = 0.0016), women who had an axillary dissection (p = 0.0446), and women who received tamoxifen (p = 0.0385).

Sentinel Lymph Node Biopsy Lowers the Rate of Lymphedema When Compared with Standard Axillary Lymph Node Dissection

Arm edema occurs in 20 to 30 per cent of patients who undergo axillary lymph node dissection (ALND) for carcinoma of the breast. Sentinel lymph node biopsy (SLNB) in lieu of ALND for staging of breast cancer significantly lowers this morbidity. We hypothesized that SLNB would have a lower lymphedema rate than conventional axillary dissection. Patients who underwent SLNB were compared with those who underwent level I and II axillary node dissection. A total of 125 patients were evaluated with 77 patients who underwent SLNB and 48 patients who underwent ALND. The arm circumference 10 cm above and 10 cm below the olecranon process was measured on both arms. In this series a difference in arm circumference greater than 3 cm between the operated and nonoperated side was defined as significant for lymphedema. Lymphedema was seen in two of 77 (2.6%) patients in the SLNB group as compared with 13 of 48 (27%) ALND patients. Given the above data patients who underwent sentinel lymph node biopsy show a significantly lower rate of lymphedema than those who had axillary lymph node dissection. This has an important impact on long-term postoperative management of patients with breast cancer.

Chronic arm morbidity after curative breast cancer treatment: prevalence and impact on quality of life

PURPOSE

To determine the prevalence of and contributing factors for chronic arm morbidity including lymphedema in breast cancer patients after treatment and to assess the impact of arm morbidity on quality of life (QOL).

PATIENTS AND METHODS

A four-question screening questionnaire was developed and mailed to a random sample of 744 breast cancer patients treated curatively in two cancer centers from 1993 to 1997. Patients were without recurrence and at least 2 years from diagnosis. Respondents were classified as with or without arm-related symptoms on the basis of the survey. Stratified random samples from each group were then invited for a detailed assessment of their symptoms and signs, including the presence of lymphedema. Their QOL was assessed by the European Organization for Research and Treatment of Cancer QOL Questionnaire C-30 and by a detailed arm problem questionnaire that assessed various aspects of daily arm functioning.

RESULTS

Approximately half of all screened patients were symptomatic and 12.5% of all assessed patients had lymphedema. Axillary dissection (AD) and axillary radiotherapy (RT) after dissection were statistically significantly related to the occurrence of arm symptoms (odds ratio for AD = 3.3, P <.001; odds ratio for RT = 3.1, P <.001). Symptomatic patients and patients with lymphedema both had impaired QOL compared with asymptomatic patients.

CONCLUSION

Treatment for breast cancer is associated with considerable arm morbidity, which has a negative impact on QOL. Arm morbidity should be carefully monitored in future studies involving local treatment modalities for breast cancer.

Comparison of side effects between sentinel lymph node and axillary lymph node dissection for breast cancer

BACKGROUND

Axillary lymph node dissection (ALND) is often associated with permanent arm side effects. Side effects after sentinel lymph node dissection (SLND) should be less common, because the surgery is less extensive.

METHODS

The study compared side effects and interference with daily life between 169 women who underwent an SLND and 78 who underwent an ALND for breast cancer. Patients rated symptom severity and interference with daily life caused by pain, numbness, limitation of arm range of motion (ROM), and arm swelling at 1, 6, and 12 months after surgery by using the Measure of Arm Symptom Survey. Repeated-measures and regression analyses for each time period were used to determine associations between symptoms and dissection type.

RESULTS

At 1 month, SLND patients reported less pain, numbness, limitation in ROM, and seromas than ALND patients. At 6 months, SLND patients had less pain, numbness, and arm swelling, and at 12 months, SLND patients had less numbness, arm swelling, and limitation in ROM than ALND patients. At 1 month, pain, numbness, and limitation in ROM interfered significantly more with daily life for ALND patients. At 6 and 12 months, only numbness interfered more with daily life for ALND patients.

CONCLUSIONS

SLND was associated with fewer side effects than ALND at all time points.

Sentinel node biopsy: an in depth appraisal

Sentinel node biopsy (SNB) in primary breast cancer has been taken-up widely to avoid the morbidity attributable to axillary node clearance (ANC). Currently many issues surrounding SNB are undecided. This review summarises why some form of axillary surgery is required and presents data on all aspects of SNB including methodology, clinical results and problems that may delay the introduction of SNB as best practice for all patients with primary breast cancer. There is no long or medium term data relating to the consequences of replacing ANC with SNB, but the mechanisms and probable magnitude of both beneficial and detrimental effects are estimated. A low level of false negative results are inherent to the technique but it is demonstrated that SNB is likely to have an only marginal (0.6%) effect on survival that would be undetectable by clinical trials. Patient sub-groups particularly likely to benefit from SNB are identified.

Physiotherapy after breast cancer surgery: results of a randomised controlled study to minimise lymphoedema

The development of secondary arm lymphoedema after the removal of axillary lymph nodes remains a potential problem for women with breast cancer. This study investigated the incidence of arm lymphoedema following axillary dissection to determine the effect of prospective monitoring and early physiotherapy intervention. Sixty-five women were randomly assigned to either the treatment (TG) or control group (CG) and assessments were made preoperatively, at day 5 and at 1, 3, 6, 12 and 24 months postoperatively. Three measurements were used for the detection of arm lymphoedema: arm circumferences (CIRC), arm volume (VOL) and multi-frequency bioimpedance (MFBIA). Clinically significant lymphoedema was confirmed by an increase of at least 200 ml from the preoperative difference between the two arms. Using this definition, the incidence of lymphoedema at 24 mo. was 21%, with a rate of 11% in the TG compared to 30% in the CG. The CIRC or MFBIA methods failed to detect lymphoedema in up to 50% of women who demonstrated an increase of at least 200 ml in the VOL of the operated arm compared to the unoperated arm. The physiotherapy intervention programme for the TG women included principles for lymphoedema risk minimisation and early management of this condition when it was identified. These strategies appear to reduce the development of secondary lymphoedema and alter its progression in comparison to the CG women. Monitoring of these women is continuing and will determine if these benefits are maintained over a longer period for women with early lymphoedema after breast cancer surgery.

Implementation of sentinel lymph node biopsy for breast cancer by surgeons in the Department of Defense

BACKGROUND

Sentinel lymph node biopsy (SLNB) for the evaluation of women with invasive breast cancer is rapidly gaining acceptance. The purpose of this study was to assess how surgeons in the Department of Defense (DOD) are incorporating SLNB into practice.

METHODS

Surgeons at all DOD hospitals were telephonically surveyed regarding their current practices with SLNB.

RESULTS

Of 66 DOD hospitals 23 (35%) are currently performing SLNB. Eleven hospitals (11 of 23, 48%) are academic centers, while 12 (12 of 23, 52%) are not teaching facilities. Seventeen (17 of 23, 77%) are in the learning phase of SLNB and follow SLNB with an axillary dissection. Eighteen (18 of 23, 78%) of facilities have surgeons who learned the procedure in residency/fellowship training. Sixteen (16 of 23, 70%) use a combination of isosulfan blue dye and sulfur colloid radioisotope. Surgeons performing SLNB are not aware of the method of examination of the sentinel node at their institution at 6 of 23 (26%) of hospitals.

CONCLUSIONS

Increasing numbers of surgeons in the DOD Healthcare System are performing SLNB. The majority learned the procedure in residency or fellowship and are using a combination of blue dye and radioisotope for the performance of SLNB.

Complicações e intercorrências associadas ao edema de braço nos três primeiros meses pós mastectomia

Este estudo buscou identificar complicações, intercorrências e aparecimento de edema pós cirurgia por câncer de mama, e fatores que poderiam estar predispondo ao linfedema do braço do lado operado. É um estudo descritivo, prospectivo e de abordagem quantitativa. A população constou de 17 mulheres submetidas à cirurgia unilateral por câncer de mama, em um hospital-escola. A coleta de dados deu-se por meio do acompanhamento semanal dos sujeitos, nos três meses pós-cirurgia. O edema apareceu em 11 mulheres, sendo, em nove, de grau leve, e, em duas de grau moderado. É importante lembrar que o edema leve poderá tornar-se grave se não tratado, devidamente. Observou-se, entre as mulheres com edema, complicações, intercorrências, e outras variáveis. Os resultados revelam a importância do acompanhamento de enfermagem no pós-operatório, e a necessidade de um melhor preparo dos profissionais para a orientação de pacientes, com o objetivo de prevenir o linfedema.