Comparison of relative versus absolute arm size change as criteria for quantifying breast cancer-related lymphedema: the flaws in current studies and need for universal methodology

Reliability, concurrent validity, and clinical feasibility of measurement methods determining volume in patients with lower limb lymphedema and healthy controls

PURPOSE

To investigate reliability, concurrent validity, and clinical feasibility of measurements assessing volume in patients with lower limb lymphedema (LLL) and healthy controls.

MATERIALS AND METHODS

To investigate intra- and interrater reliability, 47 patients with LLL and 30 healthy controls were assessed three times by two assessors. To investigate between session reliability, 50 participants were reassessed two weeks later. Each assessment included measurements of the midline region (hip circumference; suprapubic volume), leg volume (perimeter every 4 cm; Perometer®), and foot volume (water displacement; figure-of-eight method). Concurrent validity was assessed with correlation coefficients. Measurements were timed and practical limitations were reviewed. Clinical trial registration number: NCT: 05269264.

RESULTS

Measurements of the total volume of different regions showed weak to very high intraclass correlation coefficients (ICCs) (0.131-998). Absolute and relative volume differences had lower ICC values (0.360-0.976). A strong correlation was found between the total volumes of the same region. The Perometer® and figure-of-eight method were the fastest method for leg and foot volume, respectively.

CONCLUSIONS

The assessed total volumes might be more valuable in assessing the evolution of volume in bilateral LLL than the calculated absolute and relative differences between both limbs. The Perometer® and figure-of-eight method were the most time efficient for leg and foot volume, respectively.Implications for rehabilitationLymphedema is a chronic condition for which a reliable and clinically feasible assessment of volume is essential for the diagnosis, treatment decisions, and the evaluation of the treatment.This study shows that the total leg/foot volumes were more reliable than the calculated absolute and relative differences between both limbs and could therefore more valuable to evaluate bilateral lower limb lymphedema.For the assessment of leg volume, the Perometer® was the most reliable and fastest method.For the evaluation of the foot volume, the figure-of-eight method was overall the best method.

Improving quality of life after breast cancer: a comparison of two microsurgical treatment options for breast cancer-related lymphedema (BCRL)

PURPOSE

Vascularized lymph node transfer (VLNT) entails the autologous relocation of lymph nodes to a lymphedematous region of the body, whereas lymphaticovenous anastomosis (LVA) creates a direct bypass between the lymphatic and venous system. Both techniques are meant to lastingly bolster the local lymphatic drainage capacity. This study compared safety and effectiveness of VLNT and LVA in patients with chronic breast cancer related lymphedema (BCRL).

METHODS

A retrospective cohort study was conducted using data from our encrypted database composed of patients with chronic BCRL who were treated with either VLNT or LVA and had a minimum follow-up of two years. Patient-specific variables analyzed included pre- and postoperative arm circumferences, lymphedema stages and postoperative complications.

RESULTS

A total of 105 patients met the inclusion criteria, of which 96 patients demonstrated a complete follow-up period of two years. The VLNT group displayed larger preoperative circumferential measurements, evident in both in the isolated examination of the affected arm, as well as when adjusted for the contralateral unaffected arm. Significant reduction in arm volume was achieved by both groups. However, VLNT demonstrated superior relative reduction rates than LVA, neutralizing any significant arm size disparities after 24 months. Surgery duration was slightly longer for VLNT than LVA. Postoperative complications, predominantly minor, were exclusively observed in the VLNT group.

CONCLUSIONS

Both VLNT and LVA offer significant improvement for patients suffering from chronic BCRL. VLNT shows an even greater potential for improvement in more severe cases of BCRL, but involves a higher risk for (mostly minor) complications.

Managing the Morbidity: Individualizing Risk Assessment, Diagnosis, and Treatment Options for Upper Extremity Lymphedema

In the setting where breast cancer-related lymphedema (BCRL) remains a feared and common complication of breast cancer, here we review important factors for the development, diagnosis, prevention, and treatment of BCRL. We find that race/ethnicity affect BCRL development risk, that future studies should focus on understanding the biological reasons behind the increased susceptibility of certain racial minorities to BCRL, that surveillance, early detection, exercise programs, and arm compression can reduce the risk of BCRL, and that surgical techniques to preserve and restore lymphatic drainage being evaluated in randomized trials may become transformative in reducing BCRL risk for high-risk patients.

Efficacy of Immediate Lymphatic Reconstruction to Decrease Incidence of Breast Cancer-related Lymphedema: Preliminary Results of Randomized Controlled Trial

OBJECTIVE

To conduct a randomized controlled trial (RCT) on the efficacy of immediate lymphatic reconstruction (ILR) for decreasing the incidence of breast cancer-related lymphedema (BCRL) after axillary lymph node dissection (ALND).

BACKGROUND

Despite encouraging results in small studies, an appropriately powered RCT on ILR has not been performed.

METHODS

Women undergoing ALND for breast cancer were randomized in the operating room 1:1 to either ILR, if technically feasible, or no ILR (control). The ILR group underwent lymphatic anastomosis to a regional vein using microsurgical techniques; control group had no repair and cut lymphatics were ligated. Relative volume change (RVC), bioimpedance, quality of life (QoL), and compression use were evaluated at baseline and every 6 months postoperatively up to 24 months. Indocyanine green (ICG) lymphography was performed at baseline and 12 and 24 months postoperatively. The primary outcome was the incidence of BCRL, defined as ≥10% RVC from baseline in the affected extremity at 12-, 18-, or 24-month follow-up.

RESULTS

Of 72 patients randomized to ILR and 72 to control from January 2020 to March 2023, our preliminary analysis includes 99 patients with 12-month follow-up, 70 with 18-month follow-up, and 40 with 24-month follow-up. The cumulative incidence of BCRL was 9.5% in the ILR group and 32% in the control group ( P =0.014). The ILR group had lower bioimpedance values, decreased compression usage, better lymphatic function on ICG lymphography, and better QoL than the control group.

CONCLUSIONS

Preliminary results of our RCT show that ILR after ALND decreases BCRL incidence. Our goal is to finish the accrual of 174 patients with 24-month follow-up.

Seasonal Variation in Upper Limb Size, Volume, Fluid Distribution, and Lymphedema Diagnosis, Following Breast Cancer Treatment

Background: Breast cancer-related lymphedema (BCRL) is a common complication of breast cancer treatment. Anecdotal and qualitative research suggests that heat and hot weather cause an exacerbation of BCRL; however, there is little quantitative evidence to support this. The aim of this article is to investigate the relationship between seasonal climate variation and limb size, volume, fluid distribution, and diagnosis in women following breast cancer treatment. Methods and Results: Women older than the age of 35 years who had undergone treatment for breast cancer were invited to participate. Twenty-five women aged between 38 and 82 years were recruited. Seventy-two percent received surgery, radiation therapy, and chemotherapy as part of their breast cancer treatment. Participants completed anthropometric, circumferential, and bioimpedance measures and a survey on three occasions: November (spring), February (summer), and June (winter). Diagnostic criteria of >2 cm and >200 mL difference between the affected and unaffected arm, and a positive bioimpedance ratio of >1.139 for a dominant arm and >1.066 for nondominant arm was applied across the three measurement occasions. No significant correlation between seasonal variation in climate and upper limb size, volume, or fluid distribution were found in women diagnosed with or at risk of developing BCRL. Lymphedema diagnosis depends on the season and diagnostic measurement tool utilized. Conclusion: There was no statistically significant variation in limb size, volume, or fluid distribution in this population across spring, summer, and winter, although there were linked trends in these values. The diagnosis of lymphedema, however, varied between individual participants throughout the year. This has important implications for the implementation/commencement of treatment and management. Further research with a larger population in different climates is required to explore the status of women with respect to BCRL. The use of common clinical diagnostic criteria did not result in consistent diagnostic classification of BCRL for the women involved in this study.

Body mass index increases the risk of breast cancer-related lymphedema at 6-18 months after surgery: a retrospective study

PURPOSE

Breast cancer-related lymphedema (BCRL) is an incurable complication occurring after breast cancer treatment. The influence of obesity/overweight on the development of BCRL at different points after surgery was seldom verified. We aimed to determine the cut-off BMI/weight value associated with an increased risk of BCRL at different postoperative time in Chinese breast cancer survivors.

METHODS

Patients who underwent breast surgery plus axillary lymph node dissection (ALND) were retrospectively evaluated. Disease and treatment characteristics of participants were collected. BCRL was diagnosed by circumference measurements. Univariate and multivariable logistic regression was used to assess the relationship of lymphedema risk with BMI/weight and other disease- and treatment-related factors.

RESULTS

518 patients were included. Lymphedema occurred more frequently among breast cancer patients with preoperative BMI ≥ 25 kg/m² (37.88%) than among those with preoperative BMI < 25 kg/m²(23.32%), with significant differences at 6-12 and 12-18 months after surgery (χ² = 23.183, P = 0.000; χ² = 5.279, P = 0.022). By multivariable logistics analysis, preoperative BMI ≥ 30 kg/m² presented a significantly greater risk of lymphedema than a preoperative BMI < 25 kg/m² (OR [95% CI] = 2.928 [1.565, 5.480]). Other factors, including radiation (breast/chest wall + axilla vs. none: OR [95% CI] = 3.723[2.271-6.104]), was an independent risk factor for lymphedema.

CONCLUSIONS

Preoperative obesity was an independent risk factor for BCRL in Chinese breast cancer survivors, and a preoperative BMI ≥ 25 kg/m² indicated greater likelihood of lymphedema development within 6-18 months postoperatively.

Risk prediction models for breast cancer-related lymphedema: A systematic review and meta-analysis

PURPOSE

To review and critically evaluate currently available risk prediction models for breast cancer-related lymphedema (BCRL).

METHODS

PubMed, Embase, CINAHL, Scopus, Web of Science, the Cochrane Library, CNKI, SinoMed, WangFang Data, VIP Database were searched from inception to April 1, 2022, and updated on November 8, 2022. Study selection, data extraction and quality assessment were conducted by two independent reviewers. The Prediction Model Risk of Bias Assessment Tool was used to assess the risk of bias and applicability. Meta-analysis of AUC values of model external validations was performed using Stata 17.0.

RESULTS

Twenty-one studies were included, reporting twenty-two prediction models, with the AUC or C-index ranging from 0.601 to 0.965. Only two models were externally validated, with the pooled AUC of 0.70 (n = 3, 95%CI: 0.67 to 0.74), and 0.80 (n = 3, 95%CI: 0.75 to 0.86), respectively. Most models were developed using classical regression methods, with two studies using machine learning. Predictors most frequently used in included models were radiotherapy, body mass index before surgery, number of lymph nodes dissected, and chemotherapy. All studies were judged as high overall risk of bias and poorly reported.

CONCLUSIONS

Current models for predicting BCRL showed moderate to good predictive performance. However, all models were at high risk of bias and poorly reported, and their performance is probably optimistic. None of these models is suitable for recommendation in clinical practice. Future research should focus on validating, optimizing, or developing new models in well-designed and reported studies, following the methodology guidance and reporting guidelines.

Indirect partial volumetry in breast cancer-related lymphoedema: Distribution of oedema and clinical-diagnostic implications

INTRODUCTION AND OBJECTIVES

Currently, the assessment of lymphoedema related to breast cancer (BCRL) is performed through the global perimeter volumetry. We implemented an additional system with partial measures (hand, forearm, and upper arm) that allows us to approximate the segmental distribution of oedema. We used this measurement tool to determine the oedema distribution and its evolution, as well as its possible impact on clinical assessment.

METHODS

We carried out a retrospective observational study of the patients referred to our service with suspected BCRL.

INCLUSION CRITERIA

Unilateral breast cancer, availability of global and partial digital medical record, and follow-up for a minimum of 24 months. Of the 210 selected patients, 190 were considered affected (≥10% excess volume). We analysed at three time points (initial, final, and peak involvement) the oedema distribution and segmental predominance and its relationship with the evolutionary course and the severity of the process. We subsequently examined, at the initial timepoint, the concordance of the global assessment with the partial assessment for the clinical classification of the 210 patients in the initial sample.

RESULTS

The BCRL oedema was characteristically irregular, with the forearm being the most affected segment and the hand the least affected (RM ANOVA: p<0.001). The irregularity was related to its severity (χ²: p<0.001) and the evolutionary course (Student t-test: p<0.005 for the hand). Overall, disagreement of 46.67% was observed between the clinical classification of the global and partial assessment.

CONCLUSIONS

This work supports the need to add partial volumetry to the commonly used global assessment.

Intensive complex physical therapy combined with intermittent pneumatic compression versus Kinesio taping for treating breast cancer-related lymphedema of the upper limb: A randomised cross-over clinical trial

Objective

The objective of this study is to compare the effectiveness of complex physical therapy combined with intermittent pneumatic compression (CPT + IPC) versus Kinesio taping (KT) for breast cancer‐related lymphedema.

Methods

A cross‐over clinical trial was conducted in 43 women with lymphedema. All participants received two interventions: CPT + IPC and KT, both lasting 3 weeks and a washout period. The main outcome variable was the relative volume change (RVC). The secondary variables were Satisfaction Questionnaire about Textile Therapeutic Devices used for Breast Cancer‐Related Lymphedema, Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, motion range of upper limb and lymphedema‐related symptoms.

Results

The RVC reduction was greater with CPT + IPC (−2.2%, SD = 4.7) versus KT (−0.9%, SD = 1.7) (P = 0.002). KT was more satisfactory than multilayer bandaging (8.9 points difference, P < 0.001) and improved DASH score more than CPT + IPC (14.3 points difference, P = 0.002). Regarding motion ranges, only shoulder movements showed significant improvement with CPT + IPC compared with KT (differences between 5.6° and 11.4°). Of the symptoms assessed, only pain reduction showed a significant improvement with KT versus CPT + IPC (0.5 points, P = 0.035).

Conclusions

CPT + IPC achieved higher RVC and greater improvement in th shoulder motion range than KT. Conversely, KT was more satisfactory than multilayer bandaging, obtained better DASH scores and relieved pain more than CPT + IPC.

Clinical Registration

ClinicalTrial registration number: NCT03051750 (date of registration 14 February 2017).

The Boston lymphatic center's early experience with lymph node transplantation to the upper extremity

Aim

Although vascularized lymph node transplantation (VLNT) has gained recognition as an effective treatment option for lymphedema, no consensus on the timing of transplant with other lymphatic procedures has been established. The aim of this study is to describe our institutional experience with VLNT, including our staged approach and report postoperative outcomes.

Methods

A retrospective review of patients who underwent VLNT for upper extremity lymphedema from May 2017 to April 2022 was conducted. Patients were divided into fat- or fluid-dominant phenotypes based on preoperative workup. Patients with a minimum of 12-month follow-up were included. Records were reviewed for demographic, intraoperative, and surveillance data.

Results

Twenty-three patients underwent VLNT of the upper extremity during the study period, of which eighteen met the study criteria. Nine patients had fluid-dominant disease and nine patients had fat-dominant disease and had undergone prior debulking at our institution. Fluid-dominant patients demonstrated slight reductions in limb volume and hours in compression, and improvement in quality-of-life scores at twelve months. Fat-dominant patients who underwent prior debulking had a slight increase in limb volume without a change in hours of compression, and demonstrated improvements in quality-of-life scores in nearly all subdomains. Overall, 17% of patients discontinued compression therapy entirely. Improvement in extremity edema was present in 83% of postoperative MRIs.

Conclusion

VLNT had varying effects on limb measurements while reliably improving quality-of-life and allowing for the potential of discontinuing compression. Utilizing a staged approach wherein debulking is performed upfront may be particularly beneficial for patients with fat-dominant disease.

Diagnostic Criteria for Breast Cancer-Related Lymphedema of the Upper Extremity: The Need for Universal Agreement

With advances in breast cancer treatments and resultant increased survival rates, emphasis has been placed on post-treatment complications such as breast cancer-related lymphedema (BCRL), a chronic, negative sequela of breast cancer treatment. Accurate BCRL diagnosis necessitates longitudinal screening beginning at preoperative baseline. Prospective screening programs incorporating symptoms, objective measurements and clinical examination allow for early detection, early intervention, and improved BCRL prognosis. Currently, varied diagnostic criteria for BCRL exist, and this lack of consensus leads to variation in diagnostic and screening practices across institutions. This review outlines current diagnostic tools, including subjective and objective measurement methods and clinical examination. The merits of different criteria are evaluated and recommendations are made regarding measurement tools and diagnostic criteria for BCRL. Ultimately, the BCRL diagnostic process should be universalized and combine objective measurements, clinical evaluation, and symptoms assessment, and adhere to the best practices of the measurement tools used.

Subclinical Lymphedema After Treatment for Breast Cancer: Risk of Progression and Considerations for Early Intervention

BACKGROUND

Breast cancer-related lymphedema (BCRL) is a devastating complication of breast cancer (BC) treatment. The authors hypothesized that identifying subclinical lymphedema (SCL) presents an opportunity to prevent BCRL development. They aimed to assess rates of SCL progression (relative volume change [RVC], 5-10%) to BCRL (RVC, ≥10%) in women undergoing axillary surgery for BC via axillary lymph node dissection (ALND) or sentinel lymph node biopsy (SLNB).

METHODS

Patients treated for BC were prospectively screened at preoperative baseline and throughout the follow-up period using the perometer. The cohort was stratified according to nodal surgery (ALND or SLNB) to analyze rates of progression to BCRL.

RESULTS

The study cohort included 1790 patients. Of the 1359 patients who underwent SLNB, 331 (24.4%) experienced SCL, with 38 (11.5%) of these patients progressing to BCRL. Of the 431 patients who underwent ALND, 171 (39.7%) experienced SCL, with 67 (39.2%) of these patients progressing to BCRL. Relative to the patients without SCL, those more likely to experience BCRL were the ALND patients with early SCL (< 3 months postoperatively; hazard ratio [HR], 2.60; 95% confidence interval [CI], 1.58-4.27; p = 0.0002) or late SCL (≥3 months postoperatively; HR, 3.14; 95% CI, 1.95-5.05; p < 0.0001) and the SLNB patients with early SCL (HR, 6.75; 95% CI, 3.8-11.98; p < 0.0001 or late SCL (HR, 3.02; 95% CI, 1.65-5.50; p = 0.0003).

CONCLUSION

The study suggests that patients with SCL after axillary nodal surgery for BC are more likely to progress to BCRL than those who do not experience SCL. This presents a tremendous opportunity for early intervention to prevent BCRL and improve the quality of life for women treated for BC.

Agreement Between Optoelectronic Volumetry and Circumferential Girth Measurements to Diagnose Lymphedema in Patients Submitted to Axillary Radical Lymphadenectomy for Treatment of Cutaneous Melanoma

Aim: To assess the agreement between indirect and optoelectronic volumetries to diagnose lymphedema based on arm volume difference in patients with axillary lymph node dissection (ALND) for cutaneous melanoma. Methods and Results: Patients were assessed by circumferential girth measurements (truncated cone formula) to determine the upper limb volumes (indirect volumetry) and by optoelectronic volumetry (Perometer^®) of affected and control limbs. A diagnosis of lymphedema on each measuring method was defined as an absolute volume difference >200 mL or a relative volume >10%. Forty-six patients with ALND were included. There were no significant differences between the volume means or the mean absolute or relative differences measured by each method. Good correlation was observed between the volume of upper limbs for both the left (r = 0.998) and right (r = 0.985) arms. As for the diagnosis of lymphedema, an absolute volume difference >200 mL determined a prevalence of 28% (13/46) of lymphedema by indirect volumetry and 35% (16/46) by optoelectronics volumetry. The crude diagnostic agreement was 93% with a kappa = 85% (agreement adjusted by chance) between methods. If a 10% increase in the relative volume difference between the arms was used as the diagnostic criterion, prevalence was 20% (9/46) and 22% (10/46), respectively. Conclusion: There is good agreement between perometry and circumferential girth measurements when classifying patients as having a difference between arm volumes >200 mL or 10%, the most frequently used cutoffs to diagnose lymphedema.

Use of technology to facilitate a prospective surveillance program for breast cancer-related lymphedema at the Massachusetts General Hospital

Breast cancer-related lymphedema (BCRL) is a negative sequela of breast cancer (BC) caused by trauma to the lymphatic system during surgery or radiation to the axillary lymph nodes. BCRL affects approximately one in five patients treated for BC, and patients are at a lifelong risk for BCRL after treatment. Early diagnosis of BCRL may prevent its progression and reduce negative effects on quality of life, necessitating comprehensive prospective screening. This paper provides an overview of technology that may be used as part of a BCRL screening program, including objective measures such as perometry, bioimpedance spectroscopy, tissue tonometry, and three-dimensional optical imaging. Furthermore, this paper comprehensively reviews the technology incorporated into the established prospective screening program at Massachusetts General Hospital. Our prospective screening program consists of longitudinal measurements via perometry, symptoms assessment, and clinical examination by a certified lymphedema therapist (CLT) as needed. Discussion about use of perometry within the screening program and incorporation of arm volume measurements into equations to determine change over time and accurate diagnosis is included [relative volume change (RVC) and weight-adjusted change (WAC) equations]. Use of technology throughout the program is discussed, including a HIPPA-compliant online research database, the patient's electronic medical record, and incorporation of BCRL-related symptoms [BC and lymphedema symptom experience index (BCLE-SEI) survey]. Ultimately, both subjective and objective data are used to inform BCRL diagnosis and treatment by the CLT. In conclusion, the role of technology in facilitating BCRL screening is indispensable, and the continued development of objective assessment methods that are not only reliable and valid, but also cost-effective and portable will help establish BCRL screening as the standard of care for patients treated for BC.

Lymphedema Incidence After Axillary Lymph Node Dissection: Quantifying the Impact of Radiation and the Lymphatic Microsurgical Preventive Healing Approach

BACKGROUND

Axillary surgery and radiotherapy are important aspects of breast cancer treatment associated with development of lymphedema. Studies demonstrate that Lymphatic Microsurgical Preventive Healing Approach (LYMPHA) may greatly reduce the incidence of lymphedema in high-risk groups. The objective of this study is to summarize the evidence relating lymphedema incidence to axillary lymph node dissection (ALND), regional lymph node radiation (RLNR) therapy, and LYMPHA.

METHODS

We performed a literature search to identify studies involving breast cancer patients undergoing ALND with or without RLNR. Our primary outcome was the development of lymphedema. We analyzed the effect of LYMPHA on lymphedema incidence. We chose the DerSimonian and Laird random-effects meta-analytic model owing to the clinical, methodological, and statistical heterogeneity of studies.

RESULTS

Our search strategy yielded 1476 articles. After screening, 19 studies were included. Data were extracted from 3035 patients, 711 of whom had lymphedema. The lymphedema rate was significantly higher when RLNR was administered with ALND compared with ALND alone (P < 0.001). The pooled cumulative incidence of lymphedema was 14.1% in patients undergoing ALND versus 2.1% in those undergoing LYMPHA and ALND (P = 0.029). The pooled cumulative incidence of lymphedema was 33.4% in those undergoing ALND and RLNR versus 10.3% in those undergoing ALND, RLNR, and LYMPHA (P = 0.004).

CONCLUSION

Axillary lymph node dissection and RLNR are important interventions to obtain regional control for many patients but were found to constitute an increased risk of development of lymphedema. Our findings support that LYMPHA, a preventive surgical technique, may reduce the risk of breast cancer-related lymphedema in high-risk patients.

Quantifying the Impact of Axillary Surgery and Nodal Irradiation on Breast Cancer-Related Lymphedema and Local Tumor Control: Long-Term Results From a Prospective Screening Trial

PURPOSE

To independently evaluate the impact of axillary surgery type and regional lymph node radiation (RLNR) on breast cancer-related lymphedema (BCRL) rates in patients with breast cancer.

PATIENTS AND METHODS

From 2005 to 2018, 1,815 patients with invasive breast cancer were enrolled in a lymphedema screening trial. Patients were divided into the following 4 groups according to axillary surgery approach: sentinel lymph node biopsy (SLNB) alone, SLNB+RLNR, axillary lymph node dissection (ALND) alone, and ALND+RLNR. A perometer was used to objectively assess limb volume. All patients received baseline preoperative and follow-up measurements after treatment. Lymphedema was defined as a ≥ 10% relative increase in arm volume arising > 3 months postoperatively. The primary end point was the BCRL rate across the groups. Secondary end points were 5-year locoregional control and disease-free-survival.

RESULTS

The cohort included 1,340 patients with SLNB alone, 121 with SLNB+RLNR, 91 with ALND alone, and 263 with ALND+RLNR. The overall median follow-up time after diagnosis was 52.7 months for the entire cohort. The 5-year cumulative incidence rates of BCRL were 30.1%, 24.9%, 10.7%, and 8.0% for ALND+RLNR, ALND alone, SLNB+RLNR, and SLNB alone, respectively. Multivariable Cox models adjusted for age, body mass index, surgery, and reconstruction type showed that the ALND-alone group had a significantly higher BCRL risk (hazard ratio [HR], 2.66; P = .02) compared with the SLNB+RLNR group. There was no significant difference in BCRL risk between the ALND+RLNR and ALND-alone groups (HR, 1.20; P = .49) and between the SLNB-alone and SLNB+RLNR groups (HR, 1.33; P = .44). The 5-year locoregional control rates were similar for the ALND+RLNR, ALND-alone, SLNB+RLNR, and SLNB-alone groups (2.8%, 3.8%, 0%, and 2.3%, respectively).

CONCLUSION

Although RLNR adds to the risk of lymphedema, the main risk factor is the type of axillary surgery used.

[The effect of thoracic paravertebral block on seroma reduction in breast surgery - a randomized controlled trial]

BACKGROUND

Increasing number of patients are being operated because of breast cancer. Seroma is the most common problem that occurs after surgery that increases morbidity. For postoperative pain management, Thoracic Paravertebral Block (TPVB) has long been considered the gold standard technique. With performing TPVB, sympathetic nerves are also blocked.

OBJECTIVE

With this study, we aimed to search the effect of TPVB on seroma reduction in patients who undergo mastectomy and axillary node dissection surgery.

METHODS

Forty ASA I-II female patients aged 18-65, who were scheduled to go under elective unilateral mastectomy and axillary lymph node resection were included to the study. Patients were randomized into two groups as TPVB and control group. Ultrasound guided TPVB with 20 mL 0.25% bupivacaine was performed at T1 level preoperatively to the TPVB group patients. All patients were provided with i.v. patient-controlled analgesia device. Seroma formation amounts, morphine consumptions and Numeric Rating Scale (NRS) scores for pain were recorded 24^th hour postoperatively.

RESULTS AND CONCLUSIONS

Mean seroma formation at postoperative 24^th hour was 112.5±53.3 mL in the control group and 74.5±47.4 mL in the TPVB group (p=0.022). NRS scores were similar between two groups (p=0.367) at postoperative 24^th hour but mean morphine consumption at postoperative 24^th hour was 5.6±4 mg in the TPBV group, and 16.6±6.9 mg in the control group (p <0.001). TPVB reduces the amount of seroma formation while providing effective analgesia in patients who undergo mastectomy and axillary lymph node removal surgery.

Reliability and validity of a Dutch Lymphoedema Questionnaire: Cross-cultural validation of the Norman Questionnaire

OBJECTIVE

To perform the cross-cultural validation process of the Dutch Norman Questionnaire (NQ), a questionnaire for the detection and characterisation of breast-cancer related lymphoedema (BCRL) using self-reported signs and symptoms.

METHODS

Test-retest reliability and construct (including convergent, divergent and known-groups validity), face and content validity were examined in breast cancer patients with (n = 30) and without (n = 30) lymphoedema. For concurrent validity, first, agreement between the diagnostic item of the NQ and a clinical diagnosis were analysed. Second, correlations between NQ scores and clinical arm volume assessment were tested.

RESULTS

Test-retest reliability was found to be strong to very strong (ICC 0.79-0.96) in the lymphoedema group and moderate to very strong ( ICC 0.64-0.99) in the non-lymphoedema group. Seventeen out of 20 hypotheses on convergent and divergent validity were accepted. There was good face, content and known-groups validity as well. For concurrent validity, agreement between evaluation methods was only 0.462. Moderate correlations were found between 6 out of 9 symptom scores (r = 0.422-0.630) of the NQ and clinical assessment.

CONCLUSION

The Dutch NQ is a reliable and valid questionnaire for the characterisation of BCRL using self-reported signs and symptoms. Only moderate agreement for the detection of BCRL was found.

The effect of thoracic paravertebral block on seroma reduction in breast surgery – a randomized controlled trial

Background

Increasing number of patients are being operated because of breast cancer. Seroma is the most common problem that occurs after surgery that increases morbidity. For postoperative pain management, Thoracic Paravertebral Block (TPVB) has long been considered the gold standard technique. With performing TPVB, sympathetic nerves are also blocked.

Objective

With this study, we aimed to search the effect of TPVB on seroma reduction in patients who undergo mastectomy and axillary node dissection surgery.

Methods

Forty ASA I–II female patients aged 18–65, who were scheduled to go under elective unilateral mastectomy and axillary lymph node resection were included to the study. Patients were randomized into two groups as TPVB and Control group. Ultrasound guided TPVB with 20 mL 0.25% bupivacaine was performed at T1 level preoperatively to the TPVB group patients. All patients were provided with i.v. patient-controlled analgesia device. Seroma formation amounts, morphine consumptions and Numeric Rating Scale (NRS) scores for pain were recorded 24th hour postoperatively.

Results and conclusions

Mean seroma formation at postoperative 24th hour was 112.5 ± 53.3 mL in the control group and 74.5 ± 47.4 mL in the TPVB group (p = 0.022). NRS scores were similar between two groups (p = 0.367) at postoperative 24th hour but mean morphine consumption at postoperative 24th hour was 5.6 ± 4 mg in the TPBV group, and 16.6 ± 6.9 mg in the control group (p < 0.001). TPVB reduces the amount of seroma formation while providing effective analgesia in patients who undergo mastectomy and axillary lymph node removal surgery.

Comprehensive Validation Study of Quality-of-Life Questionnaire Using Objective Clinical Measures: Breast Cancer Treatment Outcome Scale (BCTOS), Brazilian Portuguese Version

INTRODUCTION

When evaluating a quality-of-life questionnaire (QLQ), many validation studies do not correlate quality-of-life scores with objective measurements of complications associated with treatment.

PATIENTS AND METHODS

We performed a cross-sectional observational study with 300 patients submitted to breast-conserving therapy. The patients answered the European Organization for Research and Treatment of Cancer (EORTC) QLQs C-30 and BR23, as well as the Brazilian Portuguese version of the Breast Cancer Treatment Outcome Scale (BCTOS) questionnaire. Retest, internal consistency, factorial analysis, convergent/divergent analysis, and Rasch evaluation were performed. All patients underwent physical evaluations to assess lymphedema, handgrip strength, shoulder range of motion, breast cosmesis, and breast pain, and these groups were compared on the basis of BCTOS scores. Receiver operating characteristic curve determined the predictive value of BCTOS scores associated with clinical practice.

RESULTS

The internal consistencies of the BCTOS domains ranged from 0.785 to 0.895. Factor analysis grouped according to the original questionnaire. Convergent validation showed differences in the sexual functioning and sexual enjoyment domains of the EORTC BR23. Analysis of known groups found that in most domains, the scores were higher in patients with lymphedema, strength deficit, shoulder range-of-motion alteration, poor breast cosmesis, breast pain, and axillary lymphadenectomy. Using a cutoff of 1.26, lymphedema was associated with the edema domain; using a cutoff of 1.33, Late Effects Normal Tissue Task Force/Subjective, Objective, Management, Analytic pain was associated with the pain domain; and using a cutoff of 2.37, the cosmetic domain was associated with subjective cosmesis.

CONCLUSION

The association of objective measurements in a validation study of quality of life qualified the study and allowed us to develop better parameters for comparisons of results of breast-conserving therapy between populations.

Intra- and Interrater Reliability and Concurrent Validity of a New Tool for Assessment of Breast Cancer-Related Lymphedema of the Upper Extremity

OBJECTIVE

The goal of this study was to develop and assess intra- and interrater reliability and validity of a clinical evaluation tool for breast cancer-related lymphedema, for use in the context of outcome evaluation in clinical trials.

DESIGN

Blinded repeated measures observational study.

SETTING

Outpatient research laboratory.

PARTICIPANTS

Breast cancer survivors with and without lymphedema (N=71).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

The assessment of intraclass correlation coefficients (ICCs) for the Breast Cancer-Related Lymphedema of the Upper Extremity (CLUE) standardized clinical evaluation tool.

RESULTS

Intrarater reliability for the CLUE tool was ICC: 0.88 (95% confidence interval [95% CI], 0.71-0.96). Interrater reliability for the CLUE tool was ICC: 0.90 (95% CI, 0.79-0.95). Concurrent validity of the CLUE score (Pearson r) was 0.79 with perometric interlimb difference and 0.53 with the Norman lymphedema overall score.

CONCLUSIONS

The CLUE tool shows excellent inter- and intrarater reliability. The overall CLUE score for the upper extremity also shows moderately strong concurrent validity with objective and subjective measures. This newly developed clinical, physical assessment of upper extremity lymphedema provides standardization and a single score that accounts for multiple constructs. Next steps include evaluation of sensitivity to change, which would establish usefulness to evaluate intervention efficacy.

Manual lymph drainage may not have a preventive effect on the development of breast cancer-related lymphoedema in the long term: a randomised trial

QUESTION

What are the short-term and long-term preventive effects of manual lymph drainage (MLD), when used in addition to information and exercise therapy, on the development of lymphoedema after axillary dissection for breast cancer?

DESIGN

Randomised controlled trial with concealed allocation, blinded assessors and intention-to-treat analysis.

PARTICIPANTS

Adults undergoing unilateral dissection for breast cancer were recruited, with 79 allocated to the experimental group and 81 to the control group.

INTERVENTION

The experimental group received guidelines about prevention of lymphoedema, exercise therapy and MLD. The control group received the same guidelines and exercise therapy, but no MLD. The interventions in both groups were delivered for 6 months.

OUTCOME MEASURES

The primary outcome was cumulative incidence of arm lymphoedema defined in four ways (≥200ml,≥2cm,≥5%, and≥10% increase), which represent the difference in arm volume or circumference between the affected and healthy sides compared with the difference before surgery. Secondary outcomes included point prevalence of lymphoedema, change in arm volume difference, shoulder range of movement, quality of life and function.

RESULTS

Incidence rates were comparable between experimental and control groups at all follow-up measurements. Sixty months after surgery, the cumulative incidence rate for the≥200ml definition was 35% for the experimental group versus 29% for the control group (RR 0.89, 95% CI 0.51 to 1.54, p=0.45); for the≥2cm definition 35% versus 38% (RR 0.93, 95% CI 0.59 to 1.45, p=0.73); for the≥5% definition 68% versus 53% (RR 1.28, 95% CI 0.97 to 1.69, p=0.08) and for the≥10% definition 28% versus 24% (RR 1.18, 95% CI 0.66 to 2.10, p=0.57). The secondary outcomes were comparable between the groups at most assessment points.

CONCLUSION

Manual lymph drainage may not have a preventive effect on the development of breast cancer-related lymphoedema in the short and long term.

TRIAL REGISTRATION

Netherlands Trial Register NTR 1055. [Devoogdt N, Geraerts I, Van Kampen M, De Vrieze T, Vos L, Neven P, Vergote I, Christiaens M-R, Thomis S, De Groef A (2018) Manual lymph drainage may not have a preventive effect on the development of breast cancer-related lymphoedema in the long term: a randomised trial. Journal of Physiotherapy 64: 245-254].

Breast cancer-related lymphedema: risk factors, precautionary measures, and treatments

Breast cancer-related lymphedema (BCRL) is a negative sequela of breast cancer treatment, and well-established risk factors include axillary lymph node dissection (ALND) and regional lymph node radiation (RLNR). BCRL affects approximately 1 in 5 patients treated for breast cancer, and it has a significant negative impact on patients' quality of life after breast cancer treatment, serving as a reminder of previous illness. This paper is a comprehensive review of the current evidence regarding BCRL risk factors, precautionary guidelines, prospective screening, early intervention, and surgical and non-surgical treatment techniques. Through establishing evidence-based BCRL risk factors, researchers and clinicians are better able to prevent, anticipate, and provide early intervention for BCRL. Clinicians can identify patients at high risk and utilize prospective screening programs, which incorporate objective measurements, patient reported outcome measures (PROM), and clinical examination, thereby creating opportunities for early intervention and, accordingly, improving BCRL prognosis. Innovative surgical techniques that minimize and/or prophylactically correct lymphatic disruption, such as axillary reverse mapping (ARM) and lymphatic-venous anastomoses (LVAs), are promising avenues for reducing BCRL incidence. Nonetheless, for those patients with BCRL who remain unresponsive to conservative methods like complete decongestive therapy (CDT), surgical treatment options aiming to reduce limb volume or restore lymphatic flow may prove to be palliative or corrective. It is only through a strong team-based approach that such a continuum of care can exist, and a multidisciplinary approach to BCRL screening, intervention, and research is therefore strongly encouraged.

Perometry versus simulated circumferential tape measurement for the detection of breast cancer-related lymphedema

PURPOSE

Despite increasing emphasis on screening and early intervention for breast cancer-related lymphedema (BCRL), there is marked heterogeneity in diagnostic methodology, including for volumetric measures. This retrospective study compared two volumetric modalities, perometry and simulated circumferential tape measurement (anatomic- and interval-based), for BCRL detection.

METHODS

Between 2005 and 2017, 287 female patients with unilateral breast cancer were prospectively screened for BCRL by perometry and the relative volume change (RVC) formula. Circumferential measurement was performed by sampling at five anatomic landmark-based points or 4-cm intervals from pairs of perometer arm diameter measurements. Volumetric conversion was by a frustum model. The Bland-Altman method was used to compare segmental volume differences. Confusion matrix analysis was performed for each circumferential measurement technique against perometry.

RESULTS

Median follow-up was 34.7 months over 4 postoperative visits. There was no difference in total arm volume comparing any of the circumferential measurement techniques to perometry. Landmark-based methods significantly underestimated upper arm volume (mean difference - 207 mL [- 336, - 78 mL]) and overestimated forearm volume (mean difference + 170 mL [+ 105, + 237 mL]). Landmark-based methods had greater sensitivity and specificity compared to 4-cm interval methods for detection of both RVC ≥ 10 and 5-10%. Landmark-based methods were comparable to perometry for detection of RVC ≥ 10%, but sensitivity was only 63.2-66.7% for RVC 5-10%.

CONCLUSIONS

This hypothesis-generating study suggested the superiority of anatomic landmark-based circumferential tape measurement compared to interval-based methods, while generating questions about the underestimation of upper arm volume and overestimation of forearm volume of circumferential tape measurement compared to perometry.

Diagnosis of Upper Quadrant Lymphedema Secondary to Cancer: Clinical Practice Guideline From the Oncology Section of the American Physical Therapy Association

The Oncology Section of the American Physical Therapy Association (APTA) developed a clinical practice guideline to aid the clinician in diagnosing secondary upper quadrant cancer-related lymphedema. Following a systematic review of published studies and a structured appraisal process, recommendations were written to guide the physical therapist and other health care clinicians in the diagnostic process. Overall clinical practice recommendations were formulated based on the evidence for each diagnostic method and were assigned a grade based on the strength of the evidence for different patient presentations and clinical utility. In an effort to maximize clinical applicability, recommendations were based on the characteristics as to the location and stage of a patient's upper quadrant lymphedema.

Diagnosis of Upper-Quadrant Lymphedema Secondary to Cancer: Clinical Practice Guideline From the Oncology Section of APTA

INTRODUCTION

The Oncology Section of APTA developed a clinical practice guideline to aid the clinician in diagnosing secondary upper-quadrant cancer-related lymphedema.

METHODS

Following a systematic review of published studies and a structured appraisal process, recommendations were written to guide the physical therapist and other health care clinicians in their diagnostic process. Overall, clinical practice recommendations were formulated on the basis of the evidence for each diagnostic method and were assigned a grade based on the strength of the evidence for different patient presentations and clinical utility.

RECOMMENDATIONS

In an effort to make these clinically applicable, recommendations were based on the characteristics as to the location and stage of a patient's upper-quadrant lymphedema.

Diagnostic Methods, Risk Factors, Prevention, and Management of Breast Cancer-Related Lymphedema: Past, Present, and Future Directions

PURPOSE OF REVIEW

Breast cancer-related lymphedema (BCRL) is a chronic, adverse, and much feared complication of breast cancer treatment, which affects approximately 20% of patients following breast cancer treatment. BCRL has a tremendous impact on breast cancer survivors, including physical impairments and significant psychological consequences. The intent of this review is to discuss recent studies and analyses regarding the risk factors, diagnosis, prevention through early screening and intervention, and management of BCRL.

RECENT FINDINGS

Highly-evidenced risk factors for BCRL include axillary lymph node dissection, lack of reconstruction, radiation to the lymph nodes, high BMI at diagnosis, weight fluctuations during and after treatment, subclinical edema within and beyond 3 months after surgery, and cellulitis in the at-risk arm. Avoidance of potential risk factors can serve as a method of prevention. Through establishing a screening program by which breast cancer patients are measured pre-operatively and at follow-ups, are objectively assessed through a weight-adjusted analysis, and are clinically assessed for signs and symptoms, BCRL can be tracked accurately and treated effectively. Management of BCRL is done by a trained professional, with research mounting towards the use of compression bandaging as a first line intervention against BCRL. Finally, exercise is safe for breast cancer patients with and without BCRL and does not incite or exacerbate symptoms of BCRL.

SUMMARY

Recent research has shed light on BCRL risk factors, diagnosis, prevention, and management. We hope that education on these aspects of BCRL will promote an informed, consistent approach and encourage additional research in this field to improve patient outcomes and quality of life in breast cancer survivors.

Bilateral Changes in Deep Tissue Environment After Manual Lymphatic Drainage in Patients with Breast Cancer Treatment-Related Lymphedema

BACKGROUND

Breast cancer treatment-related lymphedema (BCRL) arises from a mechanical insufficiency following cancer therapies. Early BCRL detection and personalized intervention require an improved understanding of the physiological processes that initiate lymphatic impairment. Here, internal magnetic resonance imaging (MRI) measures of the tissue microenvironment were paired with clinical measures of tissue structure to test fundamental hypotheses regarding structural tissue and muscle changes after the commonly used therapeutic intervention of manual lymphatic drainage (MLD).

METHODS AND RESULTS

Measurements to identify lymphatic dysfunction in healthy volunteers (n = 29) and patients with BCRL (n = 16) consisted of (1) limb volume, tissue dielectric constant, and bioelectrical impedance (i.e., non-MRI measures); (2) qualitative 3 Tesla diffusion-weighted, T₁-weighted and T₂-weighted MRI; and (3) quantitative multi-echo T₂ MRI of the axilla. Measurements were repeated in patients immediately following MLD. Normative control and BCRL T₂ values were quantified and a signed Wilcoxon Rank-Sum test was applied (significance: two-sided p < 0.05). Non-MRI measures yielded significant capacity for discriminating between arms with versus without clinical signs of BCRL, yet yielded no change in response to MLD. Alternatively, a significant increase in deep tissue T₂ on the involved (pre T₂ = 0.0371 ± 0.003 seconds; post T₂ = 0.0389 ± 0.003; p = 0.029) and contralateral (pre T₂ = 0.0365 ± 0.002; post T₂ = 0.0395 ± 0.002; p < 0.01) arms was observed. Trends for larger T₂ increases on the involved side after MLD in patients with stage 2 BCRL relative to earlier stages 0 and 1 BCRL were observed, consistent with tissue composition changes in later stages of BCRL manifesting as breakdown of fibrotic tissue after MLD in the involved arm. Contrast consistent with relocation of fluid to the contralateral quadrant was observed in all stages.

CONCLUSION

Quantitative deep tissue T₂ MRI values yielded significant changes following MLD treatment, whereas non-MRI measurements did not vary. These findings highlight that internal imaging measures of tissue composition may be useful for evaluating how current and emerging therapies impact tissue function.

Radiation therapy targets and the risk of breast cancer-related lymphedema: a systematic review and network meta-analysis

PURPOSE

New indications have been found for regional nodal irradiation (RNI) in breast cancer treatment, yet the relationship of RNI and lymphedema risk is uncertain. We sought to determine the association of RNI and lymphedema.

METHODS

We searched MEDLINE, EMBASE, and Scopus for articles in English on humans published from 1995 to 2015, using search terms breast neoplasm, treatment, and morbidity. Two investigators independently selected articles and extracted information, including manuscripts reporting incidence of lymphedema by radiation targets. Meta-analyses, review papers, case-control studies, matched-pair studies, repetitive datasets, and retrospective studies were excluded. A total of 2399 abstracts were identified and 323 corresponding articles reviewed. Twenty-one studies met inclusion criteria. Data were pooled using a random effects mixed model. Network meta-analyses were performed to determine the association of radiation targets alone and radiation targets plus extent of axillary surgery on incidence of lymphedema.

RESULTS

The addition of RNI to breast/CW irradiation was associated with an increased incidence of lymphedema (OR 2.85; 95% CI 1.24-6.55). In patients treated with sentinel lymph node biopsy or axillary sampling, there was no association of lymphedema with the addition of RNI to breast/CW irradiation (OR 1.58; 95% CI 0.54-4.66; pooled incidence 5.7 and 4.1%, respectively). Among patients treated with axillary lymph node dissection (ALND), treatment with RNI in addition to breast/CW radiation was associated with a significantly higher risk of lymphedema (OR 2.74; 95% CI 1.38-5.44; pooled incidence 18.2 and 9.4%, respectively).

CONCLUSIONS

RNI is associated with a significantly higher risk of lymphedema than irradiation of the breast/CW, particularly after ALND.

Measurement Properties of Instruments for Measuring of Lymphedema: Systematic Review

BACKGROUND

Lymphedema is a common complication of cancer treatment, resulting in swelling and subjective symptoms. Reliable and valid measurement of this side effect of medical treatment is important.

PURPOSE

The purpose of this study was to provide best evidence regarding which measurement instruments are most appropriate in measuring lymphedema in its different stages.

DATA SOURCES

The PubMed and Web of Science databases were used, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed.

STUDY SELECTION

Clinical studies on measurement instruments assessing lymphedema were reviewed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) scoring instrument for quality assessment.

DATA EXTRACTION

Data on reliability, concurrent validity, convergent validity, sensitivity, specificity, applicability, and costs were extracted.

DATA SYNTHESIS

Pooled data showed good intrarater intraclass correlation coefficients (ICCs) (.89) for bioimpedance spectroscopy (BIS) in the lower extremities and high intrarater and interrater ICCs for water volumetry, tape measurement, and perometry (.98-.99) in the upper extremities. In the upper extremities, the standard error of measurement was 3.6% (σ=0.7%) for water volumetry, 5.6% (σ=2.1%) for perometry, and 6.6% (σ=2.6%) for tape measurement. Sensitivity of tape measurement in the upper extremities, using different cutoff points, varied from 0.73 to 0.90, and specificity values varied from 0.72 to 0.78.

LIMITATIONS

No uniform definition of lymphedema was available, and a gold standard as a reference test was lacking. Items concerning risk of bias were study design, patient selection, description of lymphedema, blinding of test outcomes, and number of included participants.

CONCLUSIONS

Measurement instruments with evidence for good reliability and validity were BIS, water volumetry, tape measurement, and perometry, where BIS can detect alterations in extracellular fluid in stage 1 lymphedema and the other measurement instruments can detect alterations in volume starting from stage 2. In research, water volumetry is indicated as a reference test for measuring lymphedema in the upper extremities.

Management of the Regional Lymph Nodes in Early-Stage Breast Cancer

The management of regional nodes in early-stage invasive breast cancer continues to evolve. Improved systemic therapy has contributed to better local regional control, and at the same time it has drawn more attention to its importance. Axillary dissections have decreased, in part because of the increased efficacy of systemic therapy, and also because adjuvant therapy decisions are increasingly driven by biologic characterization of the tumor rather than pathologic nodal information. The trend toward less axillary surgery and a shift toward increased reliance on systemic and radiation therapy to address nodal disease has created interesting questions that were subsequently addressed in recent trials. We review the controversies in regional nodal management, the benefits of current treatment paradigms, the balance between less surgery and more radiation, and the potential tradeoffs vs toxicity.

Arm lymphoedema and upper limb impairments in sentinel node-negative breast cancer patients: A one year follow-up study

PURPOSE

The aim of this study is (1) to investigate the prevalence rate of arm lymphedema, pain, impaired shoulder range of motion, strength and shoulder function one year after a sentinel lymph node biopsy (SLNB) for breast cancer and (2) to determine predictive factors for these complications.

METHODS

A longitudinal study was performed. One hundred patients with a sentinel-lymph node negative breast cancer were included. All patients were measured before surgery and one year after. Arm lymphedema was measured with the perimeter, pain with the Visual Analogue Scale, shoulder range of motion with an inclinometer, strength with a handheld dynamometer and shoulder function with the Disability of Arm, Shoulder and Hand questionnaire. Patient-, breast cancer- and treatment-related variables were recorded.

RESULTS

One year after surgery 8% of sentinel node-negative breast cancer patients had developed arm lymphedema. Fifty percent of patients had pain, 30% had an impaired shoulder range of motion, 8% had a decreased handgrip strength and 49% had an impaired shoulder function. Pain, shoulder range of motion, strength and shoulder dysfunctions changed significantly over one year (p < 0.001). Higher Body Mass Index is a predictive variable for shoulder dysfunctions one year post-SLNB.

CONCLUSIONS

Prevalence rate of lymphedema and other upper limb impairments may not be underestimated after SLNB. Pain, shoulder range of motion, handgrip strength and shoulder function change significantly up to one year compared to preoperative values in sentinel node-negative breast cancer patients.

A comprehensive review of bioimpedance spectroscopy as a diagnostic tool for the detection and measurement of breast cancer-related lymphedema

As treatment for breast cancer improves and the threat of life-long chronic lymphedema becomes more prevalent, the need for effective screening tools emerges as crucial. This review was conducted using literature beginning in 1992 to analyze primary research testing the accuracy of bioimpedance spectroscopy as a diagnostic and early detection tool for breast cancer-related lymphedema. We concluded bioimpedance is an accurate diagnostic tool for pre-existent lymphedema, however, it has not been validated for early detection. J. Surg. Oncol. 2016;114:537-542. © 2016 Wiley Periodicals, Inc.

Immediate Implant Reconstruction Is Associated With a Reduced Risk of Lymphedema Compared to Mastectomy Alone: A Prospective Cohort Study

OBJECTIVE

We sought to determine the risk of lymphedema associated with immediate breast reconstruction compared to mastectomy alone.

BACKGROUND

Immediate breast reconstruction is increasingly performed at the time of mastectomy. Few studies have examined whether breast reconstruction impacts development of lymphedema.

METHODS

A total of 616 patients with breast cancer who underwent 891 mastectomies between 2005 and 2013 were prospectively screened for lymphedema at our institution, with 22.2 months' median follow-up. Mastectomies were categorized as immediate implant, immediate autologous, or no reconstruction. Arm measurements were performed preoperatively and during postoperative follow-up using a Perometer. Lymphedema was defined as 10% or more arm volume increase compared to preoperative. Kaplan-Meier and Cox regression analyses were performed to determine lymphedema rates and risk factors.

RESULTS

Of 891 mastectomies, 65% (580/891) had immediate implant, 11% (101/891) immediate autologous, and 24% (210/891) no reconstruction. The two-year cumulative incidence of lymphedema was as follows: 4.08% [95% confidence interval (CI): 2.59-6.41%] implant, 9.89% (95% CI: 4.98-19.1%) autologous, and 26.7% (95% CI: 20.4-34.4%) no reconstruction. By multivariate analysis, immediate implant [hazards ratio (HR): 0.352, P < 0.0001] but not autologous (HR: 0.706, P = 0.2151) reconstruction was associated with a significantly reduced risk of lymphedema compared to no reconstruction. Axillary lymph node dissection (P < 0.0001), higher body mass index (P < 0.0001), and greater number of nodes dissected (P = 0.0324) were associated with increased lymphedema risk.

CONCLUSIONS

This prospective study suggests that in patients for whom implant-based reconstruction is available, immediate implant reconstruction does not increase the risk of lymphedema compared to mastectomy alone.

The need for preoperative baseline arm measurement to accurately quantify breast cancer-related lymphedema

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.

Impact of Ipsilateral Blood Draws, Injections, Blood Pressure Measurements, and Air Travel on the Risk of Lymphedema for Patients Treated for Breast Cancer

PURPOSE

The goal of this study was to investigate the association between blood draws, injections, blood pressure readings, trauma, cellulitis in the at-risk arm, and air travel and increases in arm volume in a cohort of patients treated for breast cancer and screened for lymphedema.

PATIENTS AND METHODS

Between 2005 and 2014, patients undergoing treatment of breast cancer at our institution were screened prospectively for lymphedema. Bilateral arm volume measurements were performed preoperatively and postoperatively using a Perometer. At each measurement, patients reported the number of blood draws, injections, blood pressure measurements, trauma to the at-risk arm(s), and number of flights taken since their last measurement. Arm volume was quantified using the relative volume change and weight-adjusted change formulas. Linear random effects models were used to assess the association between relative arm volume (as a continuous variable) and nontreatment risk factors, as well as clinical characteristics.

RESULTS

In 3,041 measurements, there was no significant association between relative volume change or weight-adjusted change increase and undergoing one or more blood draws (P = .62), injections (P = .77), number of flights (one or two [P = .77] and three or more [P = .91] v none), or duration of flights (1 to 12 hours [P = .43] and 12 hours or more [P = .54] v none). By multivariate analysis, factors significantly associated with increases in arm volume included body mass index ≥ 25 (P = .0236), axillary lymph node dissection (P < .001), regional lymph node irradiation (P = .0364), and cellulitis (P < .001).

CONCLUSION

This study suggests that although cellulitis increases risk of lymphedema, ipsilateral blood draws, injections, blood pressure readings, and air travel may not be associated with arm volume increases. The results may help to educate clinicians and patients on posttreatment risk, prevention, and management of lymphedema.