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Jeong HH, Yoon IA, Al-Shomer FM, Suh HP, Pak CJ, Neligan P, Hong JP. Decompression of Axillary Vein: An Essential Adjunct for Advanced Lymphedema. Plast Reconstr Surg 2024; 154:218-226. [PMID: 37647513 DOI: 10.1097/prs.0000000000011032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
BACKGROUND In advanced lymphedema, lymphovenous anastomosis (LVA) can be a solution based on using the pressure gradient between the high-pressure lymphatics and the low-pressure veins. If the vein pressure is high, the effect of surgery will be less optimal. This study evaluated the effect of axillary vein perivascular scar release on LVA. METHODS This is a retrospective study of 40 upper limb stage 2 and 3 lymphedema patients divided into 2 groups with an average follow-up of 33 months (minimum of at least 12 months): the scar release group ( n = 25) and the control group ( n = 15). All patients underwent LVA with or without lymph node transfer. Demographic data, outcome (volumetric change and bioimpedence analysis [BIA]), and major vein (axillary, basilic, and cephalic) diameter changes were evaluated. RESULTS Both groups showed significant reduction in volume and BIA parameters after LVA. The scar release group (24 of 25 with lymph node transfer and 1 without) showed statistically higher reduction of BIA analysis compared with the control group at 1, 6, and 12 months after LVA. The changes in the major veins after axilla scar release showed significant changes in all 3 veins. There was a significant correlation between cephalic vein diameter reduction and BIA measurement. CONCLUSIONS The release of perivascular scar in the axillary vein may result in better outcome after LVA. This is based on the finding that scar release shows correlation between cephalic vein diameter reduction and BIA measurement suggesting reduction of venous pressure in the peripheral vein increasing the pressure gradient between the lymphatic and venous system allowing better outflow after LVA. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Hyung Hwa Jeong
- From the Department of Plastic Surgery, Asan Medical Center University of Ulsan
| | - In Ah Yoon
- From the Department of Plastic Surgery, Asan Medical Center University of Ulsan
| | - Feras M Al-Shomer
- From the Department of Plastic Surgery, Asan Medical Center University of Ulsan
| | - HyunSuk Peter Suh
- From the Department of Plastic Surgery, Asan Medical Center University of Ulsan
| | - ChangSik John Pak
- From the Department of Plastic Surgery, Asan Medical Center University of Ulsan
| | - Peter Neligan
- Division of Plastic and Reconstructive Surgery, University of Washington
| | - Joon Pio Hong
- From the Department of Plastic Surgery, Asan Medical Center University of Ulsan
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2
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Canales-Lachén E, Asunsolo Á, Manrique OJ, Blázquez J, Holguín P, Maldonado AA. The Use of Ultrasound Imaging for Upper Extremity Lymphedema after Breast Cancer: A Systematic Review. J Reconstr Microsurg 2023; 39:102-110. [PMID: 36162421 DOI: 10.1055/s-0042-1750824] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND The aim of this study was to analyze the different applications of ultrasound (US) in upper extremity lymphedema (UEL) after breast cancer. METHODS A systematic review of the literature was performed in line with the PRISMA statement using MEDLINE/PubMed databases from January 1970 to December 2021. Articles describing the application of US in patients with UEL after breast cancer were included. The quality of the study, the level of reproducibility, and the different applications and type of US technique were analyzed. RESULTS In total, 30 articles with 1,193 patients were included in the final review. Five different applications were found: (1) diagnosis of UEL (14 studies found a direct correlation between lymphedema and morphological and/or functional parameters); (2) staging/severity of UEL (9 studies found a direct correlation between the clinical stage and the soft-tissue stiffness/texture/thickness); (3) therapeutic assessment (3 studies found an improvement in the circulatory status or in the muscle/subcutaneous thickness after conservative treatments); (4) prognosis assessment of UEL (1 study found a correlation between the venous flow and the risk of UEL); and (5) surgical planning (3 studies determined the location of the lymphatic vessel for lymphovenous anastomosis [LVA] surgery). CONCLUSION Morphological and functional parameters have been correlated with the diagnosis, stage, therapeutic effect, prognosis of UEL, and surgical planning of LVA.
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Affiliation(s)
| | - Ángel Asunsolo
- Department of Surgery, Medical and Social Science, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, Madrid, Spain.,Ramón y Cajal Health Research Institute (IRYCIS), Madrid, Spain
| | - Oscar J Manrique
- Deparment of Plastic Surgery, University of Rochester Medical Center, Rochester, New York
| | - Javier Blázquez
- Department of Radiology, University Hospital Ramón y Cajal, Madrid, Spain.,Ramón y Cajal Health Research Institute (IRYCIS), Madrid, Spain
| | | | - Andrés A Maldonado
- Department of Surgery, Medical and Social Science, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, Madrid, Spain.,Ramón y Cajal Health Research Institute (IRYCIS), Madrid, Spain.,Department of Plastic Surgery, University Hospital Getafe, Madrid, Spain.,Department of Plastic, Hand and Reconstructive Surgery, BG Trauma Center Frankfurt am Main, Academic Hospital of the Goethe University Frankfurt am Main, Frankfurt am Main, Germany
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3
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Furlan C, Derchain SFM, Matheus CN, Jales RM, Sarian LO. Early Blood Flow Abnormalities in Axillary and Brachial Arteries Precede the Onset of Persistent Lymphedema in Women Treated Surgically for Breast Cancer. Lymphat Res Biol 2022; 21:118-129. [PMID: 35951016 DOI: 10.1089/lrb.2021.0085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: surgery to treat breast cancer (BC) is associated with upper limb (UL) lymphedema, which in some cases may become permanent. It is uncertain whether lymphedema results from injury to either lymphatic or blood vessels, or to both. Methods and Results: a cohort of 200 BC patients was examined 1, 3, 6, 12, and 24 months after surgery. Axillary and brachial blood vessels were evaluated using Doppler Ultrasound, and patients had their UL examined for lymphedema at each visit. Patients who developed lymphedema 24 months after surgery presented with higher mean flow velocity (MFV) and end diastolic velocity (EDV) in both axillary (MFV = 13.57 vs. 10.7 cm/s, p = 0.02; EDV = 5.62 vs. 3.47 cm/s; p = 0.004) and brachial (MFV = 11.44 vs. 8.74 cm/s; p = 0.03; EDV = 5.08 vs. 3.04; p = 0.04) arteries as early as 1 month after surgery. Similar associations were found 3, 6, and 12 months after surgery. Early abnormalities of the resistive and pulsatility indexes were also significantly associated with persistent lymphedema. EDV measured 1 month after surgery had the best performance to detect patients who will later develop long-term lymphedema, (sensitivity = 73.7%; specificity = 71.2%; negative predictive value = 57.6%). Conclusion: vascular abnormalities precede and are possible causal factors for UL lymphedema in BC patients.
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Affiliation(s)
- Cintia Furlan
- Department of Obstetrics and Gynecology, State University of Campinas (Unicamp), Campinas, São Paulo, Brazil.,Division of Gynecologic and Breast Oncology, Women's Hospital (CAISM), State University of Campinas (Unicamp), Campinas, São Paulo, Brazil
| | - Sophie F M Derchain
- Department of Obstetrics and Gynecology, State University of Campinas (Unicamp), Campinas, São Paulo, Brazil.,Division of Gynecologic and Breast Oncology, Women's Hospital (CAISM), State University of Campinas (Unicamp), Campinas, São Paulo, Brazil
| | | | - Rodrigo Menezes Jales
- Department of Obstetrics and Gynecology, Imaging Sector, Women's Hospital (CAISM), State University of Campinas (Unicamp), Campinas, São Paulo, Brazil
| | - Luís Otávio Sarian
- Department of Obstetrics and Gynecology, State University of Campinas (Unicamp), Campinas, São Paulo, Brazil.,Division of Gynecologic and Breast Oncology, Women's Hospital (CAISM), State University of Campinas (Unicamp), Campinas, São Paulo, Brazil
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5
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Response to "Delayed Breast Reconstruction on Patients With Upper Extremity Lymphedema. A Systematic Review of the Literature and Pooled Analysis" by Siotos et al. Ann Plast Surg 2019; 83:118. [PMID: 31192881 DOI: 10.1097/sap.0000000000001980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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6
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Furlan C, Matheus CN, Jales RM, Derchain S, Sarian LO. Vascular Alterations in Axillary and Brachial Vessels in Patients with Axillary Web Syndrome After Breast Cancer Surgery. Lymphat Res Biol 2017; 16:287-293. [PMID: 28961070 DOI: 10.1089/lrb.2017.0037] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Surgical manipulations of the axilla may cause a condition known as Axillary Web Syndrome (AWS). The systems compromised and the sequence of events leading to this syndrome remains unknown. This study evaluated clinical, surgical, and vascular factors associated with onset and duration of AWS after breast cancer surgery. METHODS AND RESULTS In this prospective study, 155 women were included. They were submitted to a physical examination that consisted of ultrasound Doppler of axillary and brachial vessels and the evaluation of AWS in 1, 3, and 6 months after breast cancer surgery. Women with advanced disease had a significantly higher incidence of AWS than those with early stage breast cancer (p = 0.02). In addition, women who underwent mastectomy or axillary lymph node dissection (ALND) had a significantly higher incidence of AWS in the 1-month (p < 0.01; p < 0.01) and 3-months (p < 0.01; p = 0.02) assessment rounds, respectively. The cross-sectional area of brachial artery was significantly smaller (p = 0.04) in women with AWS at the 3-months postoperative visit. The peak systolic velocity and the blood flow of the axillary artery was significantly higher in women with AWS 6 months after surgery (p < 0.03 and p = 0.02 respectively). CONCLUSION Our study confirm the combined changes of lymphatic and vascular systems in woman with AWS, since AWS was associated with more extensive dissection of axillary lymph nodes, compromised lymph nodes, and with abnormalities of the vascular parameters.
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Affiliation(s)
- Cintia Furlan
- 1 Department of Obstetrics and Gynecology, State University of Campinas (Unicamp) , Campinas, São Paulo, Brazil .,2 Division of Gynecologic and Breast Oncology, Women's Hospital (CAISM) , Unicamp, Campinas, São Paulo, Brazil
| | - Carolina Nascimben Matheus
- 1 Department of Obstetrics and Gynecology, State University of Campinas (Unicamp) , Campinas, São Paulo, Brazil .,2 Division of Gynecologic and Breast Oncology, Women's Hospital (CAISM) , Unicamp, Campinas, São Paulo, Brazil
| | - Rodrigo Menezes Jales
- 1 Department of Obstetrics and Gynecology, State University of Campinas (Unicamp) , Campinas, São Paulo, Brazil .,3 Radiology Sector, Women's Hospital (CAISM) , Unicamp, Campinas, São Paulo, Brazil
| | - Sophie Derchain
- 1 Department of Obstetrics and Gynecology, State University of Campinas (Unicamp) , Campinas, São Paulo, Brazil .,2 Division of Gynecologic and Breast Oncology, Women's Hospital (CAISM) , Unicamp, Campinas, São Paulo, Brazil
| | - Luís Otávio Sarian
- 1 Department of Obstetrics and Gynecology, State University of Campinas (Unicamp) , Campinas, São Paulo, Brazil .,2 Division of Gynecologic and Breast Oncology, Women's Hospital (CAISM) , Unicamp, Campinas, São Paulo, Brazil
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7
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Vaz MMOLL, de Jesus Guirro RR, Carrara HHA, Montezuma T, Perez CS, de Oliveira Guirro EC. Alteration of Blood Circulation in the Upper Limb Before and After Surgery for Breast Cancer Associated with Axillary Lymph Node Dissection or Sentinel Lymph Node Biopsy. Lymphat Res Biol 2017; 15:343-348. [PMID: 28956696 DOI: 10.1089/lrb.2017.0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND This aim of this study was to assess and compare arterial and venous circulation in women with axillary lymph node dissection (ALND) and sentinel lymph node biopsy (SLNB) before and after breast cancer surgery. METHODS AND RESULTS Fifty-two women took part in the study, divided into three groups: those undergoing ALND at levels I, II, and III (ALNDG), with mean age of 56.29 ± 10.85 years old; those undergoing sentinel lymph node biopsy (SLNBG), with mean age of 57.7 ± 7.07 years old; and controls without diagnosis of breast cancer (CG), with mean age of 53.92 ± 8.85 years old. Maximum venous and arterial flow velocities in upper limbs were assessed before and after surgical treatment for breast cancer by means of Doppler ultrasonography (Nicolet Vascular Versalab SE®). Data normality was assessed by using the Shapiro-Wilk's test, with normally distributed variables being analyzed with analysis of variance (ANOVA) and post hoc Tukey's test or t-test. For variables with non-normal distribution, Kruskal-Wallis' test and post hoc Dunn's test were used at p < 0.05. There was significant difference in the maximum blood flow velocities, both venous (ALNDG) and arterial (SLNBG). CONCLUSION The results suggest that ALND and SLNB can interfere with the upper limp blood circulation.
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Affiliation(s)
- Maíta M O L L Vaz
- 1 Postgraduate Program in Rehabilitation and Functional Performance, Ribeirão Preto Medical School, University of São Paulo , Ribeirão Preto, Brazil
| | - Rinaldo Roberto de Jesus Guirro
- 1 Postgraduate Program in Rehabilitation and Functional Performance, Ribeirão Preto Medical School, University of São Paulo , Ribeirão Preto, Brazil
| | - Hélio Humberto Angotti Carrara
- 2 Postgraduate Program in Obstetrics and Gynecology, Ribeirão Preto Medical School, University of São Paulo , Ribeirão Preto, Brazil
| | - Thais Montezuma
- 1 Postgraduate Program in Rehabilitation and Functional Performance, Ribeirão Preto Medical School, University of São Paulo , Ribeirão Preto, Brazil
| | - Carla Silva Perez
- 1 Postgraduate Program in Rehabilitation and Functional Performance, Ribeirão Preto Medical School, University of São Paulo , Ribeirão Preto, Brazil
| | - Elaine Caldeira de Oliveira Guirro
- 1 Postgraduate Program in Rehabilitation and Functional Performance, Ribeirão Preto Medical School, University of São Paulo , Ribeirão Preto, Brazil
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Deshmukh VR, Bhardwaj H, Khan F, Jacob TG. Aberrant Cutaneous Nerve Loops in the Axilla. ACTA MEDICA (HRADEC KRÁLOVÉ) 2017; 60:51-54. [DOI: 10.14712/18059694.2017.50] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
During routine dissection classes, conducted for first year undergraduate medical students, we encountered a rare anatomical variation in relation to the intercostobrachial nerve (ICBN). The ICBN represents the lateral undivided cutaneous branch of second intercostal nerve. In this case, the ICBN formed nerve loops with branches of the lateral cutaneous branch of the third intercostal nerve. These loops eventually gave branches that probably supplied the floor of the axilla and proximal arm. Nowadays, this ICBN is gaining clinical importance during the axillary lymph node dissections and mammary gland surgeries. Damage to the ICBN, may results in the sensory deficits in patients undergoing surgery. In our case report, ICBN was making aberrant nerve loop along with the branches from the third intercostal nerve. Knowledge regarding the origin, formation and route of ICBN is of clinical significance to axillary surgeons, radiologist and anesthesiologists.
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9
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Correlation Between Upper Limb Volume and Arterial and Venous Blood Flow Velocity in Lymphedema Secondary to Breast Cancer Treatment. J Manipulative Physiol Ther 2017; 40:241-245. [DOI: 10.1016/j.jmpt.2017.02.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 11/16/2015] [Accepted: 04/05/2016] [Indexed: 11/23/2022]
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10
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Manual Lymphatic Drainage in Blood Circulation of Upper Limb With Lymphedema After Breast Cancer Surgery. J Manipulative Physiol Ther 2017; 40:246-249. [DOI: 10.1016/j.jmpt.2017.02.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 11/26/2015] [Accepted: 04/05/2016] [Indexed: 12/20/2022]
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11
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Effect of Arm Position on Circumference Measurement of Upper Arms in Healthy and in Women With Breast Cancer–Related Lymphedema. REHABILITATION ONCOLOGY 2017. [DOI: 10.1097/01.reo.0000000000000054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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12
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Rezende MS, Marsengo AL, de Jesus Guirro RR, de Oliveira Guirro EC. Blood Flow Velocity in Brachial and Subclavian Vessels Immediately After Compressive Procedures for Treatment of Postcancer Therapy Lymphedema in Breast Cancer: A Randomized Blind Clinical Trial. Lymphat Res Biol 2017; 15:23-31. [PMID: 28278070 DOI: 10.1089/lrb.2016.0022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE This study sought to evaluate the effect of elastic compression, functional compressive bandaging, and kinesiotherapy on blood flow of the upper limb with lymphedema secondary to the treatment of breast cancer. METHODS This was a randomized blind crossover clinical trial with a washout period of 7 days between treatments. We evaluated 20 women with a mean age of 66.85 years (standard deviation = 11.76), undergoing three types of therapeutic procedures randomly applied by lot: kinesiotherapy, functional compressive bandaging + kinesiotherapy (FCB), and elastic compression + kinesiotherapy (EC). Blood flow, including mean and maximum velocity, was assessed by Doppler ultrasound before and after the therapeutic procedure (immediately after, 15 minutes, and 30 minutes). We used two-way analysis of variance for repeated measures followed by Bonferroni's test, considering a significance level of 5%. RESULTS The EC and FCB groups showed a significant increase in the mean velocity of blood flow in the axillary and brachial arteries and veins compared to the group that received only kinesiotherapy (p < 0.05), but no difference between them (p > 0.05). Moreover, the EC and FCB groups showed greater increase in maximum velocity of blood flow in the brachial artery (p < 0.05) compared to the group that received only kinesiotherapy, but no difference between them (p > 0.05). CONCLUSION Elastic compression and functional compressive bandaging combined with kinesiotherapy increased blood flow of upper limb lymphedema.
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Affiliation(s)
- Monique Silva Rezende
- 1 Postgraduate Program in Rehabilitation and Functional Performance, Medical School of Ribeirão Preto, University of São Paulo , São Paulo, Brazil
| | - Ana Luiza Marsengo
- 2 Undergraduate Student, Medical School of Ribeirão Preto, University of São Paulo , São Paulo, Brazil
| | - Rinaldo Roberto de Jesus Guirro
- 1 Postgraduate Program in Rehabilitation and Functional Performance, Medical School of Ribeirão Preto, University of São Paulo , São Paulo, Brazil
| | - Elaine Caldeira de Oliveira Guirro
- 1 Postgraduate Program in Rehabilitation and Functional Performance, Medical School of Ribeirão Preto, University of São Paulo , São Paulo, Brazil
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13
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Sun F, Skolny MN, Swaroop MN, Rawal B, Catalano PJ, Brunelle CL, Miller CL, Taghian AG. The need for preoperative baseline arm measurement to accurately quantify breast cancer-related lymphedema. Breast Cancer Res Treat 2016; 157:229-240. [PMID: 27154787 DOI: 10.1007/s10549-016-3821-0] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 05/02/2016] [Indexed: 11/30/2022]
Abstract
Breast cancer-related lymphedema (BCRL) is a feared outcome of breast cancer treatment, yet the push for early screening is hampered by a lack of standardized quantification. We sought to determine the necessity of preoperative baseline in accounting for temporal changes of upper extremity volume. 1028 women with unilateral breast cancer were prospectively screened for lymphedema by perometry. Thresholds were defined: relative volume change (RVC) ≥10 % for clinically significant lymphedema and ≥5 % including subclinical lymphedema. The first postoperative measurement (pseudo-baseline) simulated the case of no baseline. McNemar's test and binomial logistic regression models were used to analyze BCRL misdiagnoses. Preoperatively, 28.3 and 2.9 % of patients had arm asymmetry of ≥5 and 10 %, respectively. Without baseline, 41.6 % of patients were underdiagnosed and 40.1 % overdiagnosed at RVC ≥ 5 %, increasing to 50.0 and 54.8 % at RVC ≥ 10 %. Increased pseudo-baseline asymmetry, increased weight change between baselines, hormonal therapy, dominant use of contralateral arm, and not receiving axillary lymph node dissection (ALND) were associated with increased risk of underdiagnosis at RVC ≥ 5 %; not receiving regional lymph node radiation was significant at RVC ≥ 10 %. Increased pseudo-baseline asymmetry, not receiving ALND, and dominant use of ipsilateral arm were associated with overdiagnosis at RVC ≥ 5 %; increased pseudo-baseline asymmetry and not receiving ALND were significant at RVC ≥ 10 %. The use of a postoperative proxy even early after treatment results in poor sensitivity for identifying BCRL. Providers with access to patients before surgery should consider the consequent need for proper baseline, with specific strategy tailored by institution.
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Affiliation(s)
- Fangdi Sun
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, 100 Blossom Street, Boston, MA, 02114, USA
| | - Melissa N Skolny
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, 100 Blossom Street, Boston, MA, 02114, USA
| | - Meyha N Swaroop
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, 100 Blossom Street, Boston, MA, 02114, USA
| | - Bhupendra Rawal
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02115, USA
| | - Paul J Catalano
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02115, USA
| | - Cheryl L Brunelle
- Department of Physical and Occupational Therapy, Massachusetts General Hospital, Harvard Medical School, 100 Blossom Street, Boston, MA, 02114, USA
| | - Cynthia L Miller
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, 100 Blossom Street, Boston, MA, 02114, USA
| | - Alphonse G Taghian
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, 100 Blossom Street, Boston, MA, 02114, USA.
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de Abreu Junior GF, Pitta GBB, Araújo M, Castro ADA, de Azevedo Junior WF, Miranda Junior F. Ultrasonografic changes in the axillary vein of patients with lymphedema after mastectomy. Rev Col Bras Cir 2015; 42:81-92. [PMID: 26176673 DOI: 10.1590/0100-69912015002004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 08/15/2014] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE To determine the prevalence of sonographic abnormalities (SA) in the axillary vein of patients with and without post-mastectomy lymphedema. METHODS We studied a sample of 80 women, divided into two equal groups, with and without lymphedema, with B mode ultrasound, color and pulsed Doppler. The primary variable, SA, is defined as change in the venous diameter, parietal thickening, intraluminal images, compressibility, parietal collapse at inspiration and feature of the axillary venous flow on the operated side. Secondary variables were: stage of lymphedema, surgical technique, number of radio and chemotherapy sessions, limb volume, weight and age. The differences between the proportions in the groups were determined using the Chi-square test and / or Fisher's test. For continuous variables, we used the Mann-Whitney Test. To estimate the magnitude of the associations, we used the prevalence rate of SA in both groups as a measure of frequency, and as a measure of association, the prevalence ratio (PR) obtained as a function of relative risk (RR) and estimated by the test Mantel-Haenszel homogeneity test. We adopted the statistical significance level of 5% (p < 0.05). RESULTS only the criterion "parietal thickening" was strongly associated with the lymphedema group (p = 0.001). The prevalence of SA was 55% in patients with lymphedema and 17.5% in the group without it, with difference in prevalence of 37.5%. CONCLUSION the prevalence of SA was higher in patients undergoing mastectomy with lymphedema than in those without lymphedema.
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Affiliation(s)
| | | | - Marcelo Araújo
- Department of Health Sciences, Universidade Estadual de Santa Cruz, Ilheus, BA, Brazil
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Hwang JH, Lee CH, Lee HH, Kim SY. A new soft tissue volume measurement strategy using ultrasonography. Lymphat Res Biol 2014; 12:89-94. [PMID: 24521479 DOI: 10.1089/lrb.2013.0030] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract Various techniques are available for measuring the status of lymphedema. A modified imaging technique using ultrasonography was developed to measure the structure of soft tissue area in a cost-effective manner. The purpose of this study was to measure the reliability and the accuracy of this new method. Ultrasonography was performed on both arms of twenty healthy female participants. At 10 cm above (AE) and below (BE) the elbow crease, soft tissue thickness at medial, lateral, inferior, and superior locations were measured by two examiners with minimal unnecessary pressure. After measuring twice on 16 sites for each participant, the amount of soft tissue in the cross-sectional area (ΔCSA) was acquired by a designed formulation. The ΔCSA was also compared with volumetry data (Perometer(®)). Cronbach's alpha coefficient test was used for statistics. The intra-class and inter-class reliability measurements for all soft tissue areas were very strong (α=0.980 and 0.960, respectively; p<0.01). All AE and BE reliabilities showed very strong correlation and strong correlation of inter-BE measurement. All reliabilities of ΔCSA were very strong (≥0.950). All CCs (correlation coefficients) between ΔCSA, circumference, and volumetry were strong for AE and BE measurements, except for ΔCSA and circumference at BE. The strongest CC was between volumetry and circumference measurements. This study suggests that measuring the ΔCSA by ultrasonography could be an alternative way to measure the status of soft tissue indirectly with structural consideration.
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Affiliation(s)
- Ji Hye Hwang
- 1 Department of Physical Medicine and Rehabilitation, Samsung Medical Center, Center for Clinical Research, Sungkyunkwan University School of Medicine , Seoul, Republic of Korea
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Defining a threshold for intervention in breast cancer-related lymphedema: what level of arm volume increase predicts progression? Breast Cancer Res Treat 2013; 140:485-94. [PMID: 23912961 DOI: 10.1007/s10549-013-2655-2] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Accepted: 07/26/2013] [Indexed: 10/26/2022]
Abstract
The purpose of this study is to evaluate arm volume measurements and clinico-pathologic characteristics of breast cancer patients to define a threshold for intervention in breast cancer-related lymphedema. We prospectively performed arm volume measurements on breast cancer patients using a Perometer. Arm measurements were performed pre- and post-operatively, and change in arm volume was quantified using a relative volume change (RVC) equation. Patient and treatment risk factors were evaluated. Cox proportional hazards models with time-dependent covariates for RVC were used to evaluate whether RVC elevations of ≥3 to <5 % or ≥5 to <10 % occurring ≤3 months or >3 months after surgery were associated with progression to ≥10 % RVC. 1,173 patients met eligibility criteria with a median of 27 months post-operative follow-up. The cumulative incidence of ≥10 % RVC at 24 months was 5.26 % (95 % CI 4.01-6.88 %). By multivariable analysis, a measurement of ≥5 to <10 % RVC occurring >3 months after surgery was significantly associated with an increased risk of progression to ≥10 % RVC (HR 2.97, p < 0.0001), but a measurement of ≥3 to <5 % RVC during the same time period was not statistically significantly associated (HR 1.55, p = 0.10). Other significant risk factors included a measurement ≤3 months after surgery with RVC of ≥3 to <5 % (p = 0.007), ≥5 to <10 % (p < 0.0001), or ≥10 % (p = 0.023), axillary lymph node dissection (ALND) (p < 0.0001), and higher BMI at diagnosis (p = 0.0028). Type of breast surgery, age, number of positive or number of lymph nodes removed, nodal radiation, chemotherapy, and hormonal therapy were not significant (p > 0.05). Breast cancer patients who experience a relative arm volume increase of ≥3 to <5 % occurring >3 months after surgery do not have a statistically significant increase in risk of progression to ≥10 %, a common lymphedema criterion. Our data support utilization of a ≥5 to <10 % threshold for close monitoring or intervention, warranting further assessment. Additional risk factors for progression to ≥10 % include ALND, higher BMI, and post-operative arm volume elevation.
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DiSipio T, Rye S, Newman B, Hayes S. Incidence of unilateral arm lymphoedema after breast cancer: a systematic review and meta-analysis. Lancet Oncol 2013; 14:500-15. [PMID: 23540561 DOI: 10.1016/s1470-2045(13)70076-7] [Citation(s) in RCA: 1099] [Impact Index Per Article: 99.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The body of evidence related to breast-cancer-related lymphoedema incidence and risk factors has substantially grown and improved in quality over the past decade. We assessed the incidence of unilateral arm lymphoedema after breast cancer and explored the evidence available for lymphoedema risk factors. METHODS We searched Academic Search Elite, Cumulative Index to Nursing and Allied Health, Cochrane Central Register of Controlled Trials (clinical trials), and Medline for research articles that assessed the incidence or prevalence of, or risk factors for, arm lymphoedema after breast cancer, published between Jan 1, 2000, and June 30, 2012. We extracted incidence data and calculated corresponding exact binomial 95% CIs. We used random effects models to calculate a pooled overall estimate of lymphoedema incidence, with subgroup analyses to assess the effect of different study designs, countries of study origin, diagnostic methods, time since diagnosis, and extent of axillary surgery. We assessed risk factors and collated them into four levels of evidence, depending on consistency of findings and quality and quantity of studies contributing to findings. FINDINGS 72 studies met the inclusion criteria for the assessment of lymphoedema incidence, giving a pooled estimate of 16.6% (95% CI 13.6-20.2). Our estimate was 21.4% (14.9-29.8) when restricted to data from prospective cohort studies (30 studies). The incidence of arm lymphoedema seemed to increase up to 2 years after diagnosis or surgery of breast cancer (24 studies with time since diagnosis or surgery of 12 to <24 months; 18.9%, 14.2-24.7), was highest when assessed by more than one diagnostic method (nine studies; 28.2%, 11.8-53.5), and was about four times higher in women who had an axillary-lymph-node dissection (18 studies; 19.9%, 13.5-28.2) than it was in those who had sentinel-node biopsy (18 studies; 5.6%, 6.1-7.9). 29 studies met the inclusion criteria for the assessment of risk factors. Risk factors that had a strong level of evidence were extensive surgery (ie, axillary-lymph-node dissection, greater number of lymph nodes dissected, mastectomy) and being overweight or obese. INTERPRETATION Our findings suggest that more than one in five women who survive breast cancer will develop arm lymphoedema. A clear need exists for improved understanding of contributing risk factors, as well as of prevention and management strategies to reduce the individual and public health burden of this disabling and distressing disorder. FUNDING The National Breast Cancer Foundation, Australia.
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Affiliation(s)
- Tracey DiSipio
- School of Public Health and Social Work, Institute of Health and Biomedical Innovation, Queensland University of Technology, Queensland, Australia.
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Intercostobrachial nerves as a novel anatomic landmark for dividing the axillary space in lymph node dissection. ISRN ONCOLOGY 2013; 2013:279013. [PMID: 23401796 PMCID: PMC3563178 DOI: 10.1155/2013/279013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Accepted: 12/16/2012] [Indexed: 11/17/2022]
Abstract
Purpose. Our aim was to assess the feasibility of using the intercostobrachial nerves (ICBNs) as a possible new anatomic landmark for axillaries lymph node dissection in breast cancer patients. Background Data Summary. The preservation of ICBN is now an accepted procedure in this type of dissection; however, it could be improved further to reduce the number of postoperative complications. The axillary space is divided into lower and upper parts by the ICBN-a thorough investigation of the metastasis patterns in lymph nodes found in this area could supply new information leading to such improvements. Methods. Seventy-two breast cancer patients, all about to undergo lymph node dissection and with sentinel lymph nodes identified, were included in this trial. The lymph nodes were collected in two groups, from lower and upper axillary spaces, relative to the intercostobrachial nerves. The first group was further subdivided into sentinel (SLN) and nonsentinel (non-SLN) nodes. All lymph nodes were tested to detect macro- and micrometastasis. Results. All the sentinel lymph nodes were found under the intercostobrachial nerves; more than 10 lymph nodes were located in that space. Moreover, when lymph nodes macrometastasize or micrometastasize above the intercostobrachial nerves, we also observe metastasis-positive nodes under the nerves; when the lower group nodes show no metastasis, the upper group is also metastasis free. Conclusions. Our results show that the intercostobrachial nerves are good candidates for a new anatomic landmark to be used in lymph node dissection procedure.
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Change in blood flow velocity demonstrated by Doppler ultrasound in upper limb after axillary dissection surgery for the treatment of breast cancer. Breast Cancer Res Treat 2011; 127:697-704. [DOI: 10.1007/s10549-011-1456-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2011] [Accepted: 03/14/2011] [Indexed: 11/27/2022]
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Montgomery LD, Dietrich MS, Armer JM, Stewart BR, Ridner SH. Segmental blood flow and hemodynamic state of lymphedematous and nonlymphedematous arms. Lymphat Res Biol 2011; 9:31-42. [PMID: 21417765 PMCID: PMC3060729 DOI: 10.1089/lrb.2010.0012] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Findings regarding the influence hemodynamic factors, such as increased arterial blood flow or venous abnormalities, on breast cancer treatment-related lymphedema are mixed. The purpose of this study was to compare segmental arterial blood flow, venous blood return, and blood volumes between breast cancer survivors with treatment-related lymphedema and healthy normal individuals without lymphedema. METHODS AND RESULTS A Tetrapolar High Resolution Impedance Monitor and Cardiotachometer were used to compare segmental arterial blood flow, venous blood return, and blood volumes between breast cancer survivors with treatment-related lymphedema and healthy normal volunteers. Average arterial blood flow in lymphedema-affected arms was higher than that in arms of healthy normal volunteers or in contralateral nonlymphedema affected arms. Time of venous outflow period of blood flow pulse was lower in lymphedema-affected arms than in healthy normal or lymphedema nonaffected arms. Amplitude of the venous component of blood flow pulse signal was lower in lymphedema-affected arms than in healthy or lymphedema nonaffected arms. Index of venular tone was also lower in lymphedema-affected arms than healthy or lymphedema nonaffected arms. CONCLUSIONS Both arterial and venous components may be altered in the lymphedema-affected arms when compared to healthy normal arms and contralateral arms in the breast cancer survivors.
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Affiliation(s)
| | | | - Jane M. Armer
- University of Missouri School of Nursing, Columbia, Missouri
| | - B. R. Stewart
- University of Missouri School of Nursing, Columbia, Missouri
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Rezende LFD, Rocha AVR, Gomes CS. Avaliação dos fatores de risco no linfedema pós-tratamento de câncer de mama. J Vasc Bras 2010. [DOI: 10.1590/s1677-54492010000400005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
A principal complicação tardia no pós-operatório de câncer de mama é o desenvolvimento do linfedema, uma doença crônica, progressiva, geralmente incurável. O aumento do volume do membro pode desfigurar a imagem corporal, assim como aumentar a morbidade física e psicológica da paciente, além de promover significativo prejuízo para as funções. O presente estudo foi desenvolvido por meio de uma revisão sistemática a partir do cruzamento aleatório das palavras-chave: "linfedema", "compensações linfáticas", "sistema linfático", "dissecção axilar", "fatores de risco" e "câncer de mama". Foram selecionados 18 artigos entre os anos de 1979 e 2009, nos quais foram encontrados como principais fatores de risco para o desenvolvimento do linfedema a radioterapia, radioterapia axilar, infecção, dissecção axilar seguida de radioterapia, obesidade, número de linfonodos retirados e comprometidos e agressividade da cirurgia. As formas de compensação linfática após a dissecção axilar, como as anastomoses linfo-linfáticas, podem ser prejudicadas pela formação cicatricial, seroma pós-operatório, radioterapia e exercícios inadequados para reabilitação de ombro no câncer de mama.
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Nielsen I, Gordon S, Selby A. Breast cancer-related lymphoedema risk reduction advice: A challenge for health professionals. Cancer Treat Rev 2008; 34:621-8. [DOI: 10.1016/j.ctrv.2007.11.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2007] [Revised: 11/19/2007] [Accepted: 11/20/2007] [Indexed: 11/29/2022]
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Abstract
Ultrasound is the initial imaging modality of choice when evaluating the upper extremity venous system. When sonographic findings are equivocal or nondiagnostic, particularly in evaluating the central deep veins, MR venography or catheter venography correlation may be helpful. Ultrasound provides an accurate, rapid, low-cost, portable, noninvasive method for screening, mapping, and surveillance of the upper extremity venous system.
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Affiliation(s)
- Therese M Weber
- Department of Radiology, University of Alabama at Birmingham, 619 19th Street, South, JT N312, Birmingham, AL 35249-6830, USA.
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Lane KN, Dolan LB, Worsley D, McKenzie DC. Upper extremity lymphatic function at rest and during exercise in breast cancer survivors with and without lymphedema compared with healthy controls. J Appl Physiol (1985) 2007; 103:917-25. [PMID: 17585046 DOI: 10.1152/japplphysiol.00077.2007] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Lymphoscintigraphy was used to measure lymphatic function at rest and during exercise in breast cancer survivors with lymphedema (BCRL, n = 10), breast cancer survivors (BC, n = 10), and controls (Cont, n = 10). After injection of 99mTc-antimony colloid to the hands, subjects rested or performed 12 repeated sets of arm cranking for 2.5 min at 0.6 W/kg followed by 2.5 min of rest. One-minute spot views were taken with a gamma-radiation camera immediately postinjection and every 10 min over 60 min to calculate clearance rate. As well, an upper body scan was taken at 65 min postinjection to measure radiopharmaceutical uptake in the axilla (Ax) and forearm (Fore). All groups displayed similar increases in clearance rate with exercise ( P = 0.000). Ax significantly increased with exercise in Cont only [Cont: (mean ± SD) 4.9 ± 2.6 vs. 7.9 ± 4.2%, P = 0.000; BCRL: 1.4 ± 1.2 vs. 1.7 ± 2.1%, P = 0.531; BC: 3.9 ± 3.4 vs. 5.2 ± 3.2%, P = 0.130], whereas Fore, indicating dermal backflow, significantly increased in BCRL only (BCRL: 2.4 ± 0.87 vs. 4.4 ± 2.0%, P = 0.004; BC: 1.1 ± 0.25 vs. 1.1 ± 0.31%, P = 0.784; Cont: 0.93 ± 0.26 vs. 1.0 ± 0.20%, P = 0.296). The results indicate that, in women with BCRL, exercise causes radiopharmaceuticals to clear from the hand at the same rate as BC and Cont, but, instead of reaching the axilla, a greater amount of activity gets trapped in the dermis of the forearm. BC, meanwhile, have similar lymphatic function as Cont; however, there is a highly variable response that may suggest that some BC subjects may be at risk for developing lymphedema.
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Affiliation(s)
- Kirstin N Lane
- Division of Sports Medicine, University of British Columbia, 3055 Wesbrook Mall, Vancouver, BC, Canada, V6T 1Z3.
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Purushotham AD, Bennett Britton TM, Klevesath MB, Chou P, Agbaje OF, Duffy SW. Lymph node status and breast cancer-related lymphedema. Ann Surg 2007; 246:42-5. [PMID: 17592289 PMCID: PMC1899199 DOI: 10.1097/01.sla.0000259390.51203.7b] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE This study examines the association between nodal positivity and risk of developing breast cancer-related lymphedema (BCRL) in patients who underwent axillary lymph node dissection (ALND). SUMMARY BACKGROUND DATA The pathophysiology of BCRL is poorly understood. It has been assumed that one of the factors predisposing to the development of BCRL is nodal positivity, although retrospective series have produced contradictory findings. As these studies have included treatment regimens known to cause BCRL, such as axillary radiotherapy, any relationship between nodal positivity and the development of BCRL remains speculative. METHODS A total of 212 patients who had undergone ALND for invasive breast cancer had arm volume measurements preoperatively, and at intervals postoperatively. No patient received axillary radiotherapy. Arm volumes were obtained by measuring serial arm circumferences every 4 cm up the arm and then calculated by using the formula for the volume of a truncated cone. Robust regression techniques were used to analyze the effects of node positivity, age, preoperative body mass index, and wound infection on arm volume excess. RESULTS In all, 64 of 212 (30%) patients were node positive. Contrary to previous assumptions, positive node status was significantly inversely associated with arm volume after adjusting for tumor size, time since operation, and allowing for correlated observations within subjects. Furthermore, the number of positive nodes also correlated inversely with arm volume. CONCLUSION These results are counterintuitive to the conventional understanding of the pathophysiology of BCRL. A possible explanation is that patients who develop disease in axillary lymph nodes and subsequently undergo ALND have more time and ability to develop lymphatic collaterals, which may provide adequate lymphatic drainage following surgery, thereby reducing the risk of developing BCRL.
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Bennett Britton TM, Buczacki SJA, Turner CL, Vowler SL, Pain SJ, Purushotham AD. Venous changes and lymphoedema 4 years after axillary surgery for breast cancer. Br J Surg 2007; 94:833-4. [PMID: 17335123 DOI: 10.1002/bjs.5711] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Lymphoedema is progressive
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Affiliation(s)
- T M Bennett Britton
- Department of Academic Oncology, King's College London and Guy's and St Thomas' NHS Foundation Trust, London, UK
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Bridenbaugh E. Literature watch. Complete and specific inhibition of adult lymphatic regeneration by a novel VEGFR-3 neutralizing antibody. Lymphat Res Biol 2005; 3:87-8. [PMID: 16000057 DOI: 10.1089/lrb.2005.3.87] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Affiliation(s)
- Eric Bridenbaugh
- Department of Medical Physiology, Texas A&M University System HSC, College Station, TX, USA
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