Breast reconstruction and risk of lymphedema after mastectomy: A prospective cohort study with 10 years of follow-up

Etiology and treatment of cancer-related secondary lymphedema

Lymphedema and specifically cancer-related lymphedema is not the main focus for both patients and physicians dealing with cancer. Its etiology is an unfortunate complication of cancer treatment. Although lymphedema treatments have gained an appreciable consensus, many practitioners have developed and prefer their own specific protocols and this is especially true for conventional (manual) versus surgical treatments. This collection of presentations explores the incidence and genetics of cancer-related lymphedema, early detection and monitoring techniques, both conventional and operative treatment options, and the importance and role of exercise for patients with cancer-related lymphedema. These assembled presentations provide valuable insights into the challenges and opportunities presented by cancer-related lymphedema including the latest research, treatments, and exercises available to improve patient outcomes and quality of life.

Risk factors of unilateral breast cancer-related lymphedema: an updated systematic review and meta-analysis of 84 cohort studies

PURPOSE

To review and update the incidence and risk factors for breast cancer-related lymphedema based on cohort studies.

METHODS

The study was guided by the Joanna Briggs Institute methodology and the Cochrane handbook for systematic reviews. PubMed, EMBASE, CINAHL, Scopus, Web of Science, The Cochrane Library, CNKI, SinoMed, and Wan Fang Database were searched from inception to November 15, 2021. Cohort studies reported adjusted risk factors were selected. PRISMA guideline was followed. Study quality were evaluated using the Newcastle-Ottawa scale. Random-effects models were adopted. The robustness of pooled estimates was validated by meta-regression and subgroup analysis. Lymphedema incidence and adjusted risk factors in the multivariable analyses with hazard / odds ratios and 95% CIs were recorded.

RESULTS

Eighty-four cohort studies involving 58,358 breast cancer patients were included. The pooled incidence of lymphedema was 21.9% (95% CI, 19.8-24.0%). Fourteen factors were identified including ethnicity (black vs. white), higher body mass index, higher weight increase, hypertension, higher cancer stage (III vs. I-II), larger tumor size, mastectomy (vs. breast conservation surgery), axillary lymph nodes dissection, more lymph nodes dissected, higher level of lymph nodes dissection, chemotherapy, radiotherapy, surgery complications, and higher relative volume increase postoperatively. Additionally, breast reconstruction surgery, and adequate finance were found to play a protective role. However, other variables such as age, number of positive lymph nodes, and exercise were not correlated with risk of lymphedema.

CONCLUSION

Treatment-related factors still leading the development of breast cancer-related lymphedema. Other factors such as postoperative weight increase and finance status also play a part. Our findings suggest the need to shift the focus from treatment-related factors to modifiable psycho-social-behavioral factors.

Evidence-Based Practice Guideline for the Management of Lymphedema Proposed by the Japanese Lymphedema Society

Background: Secondary lymphedema mostly occurs as an aftereffect of cancer treatment, and it is estimated that 100,000-150,000 patients are affected in Japan. An estimated 3500 patients, develop lymphedema of the lower and upper extremities each year secondary to uterine and breast cancer treatment. Medical reimbursement was first instituted in April 2008 by the Ministry of Health, Labour and Welfare in Japan. Since 2008, we have developed guidelines regarding treatment options for patients with lymphedema based on scientific evidence. This is the third edition of the guidelines established by the Japanese Lymphedema Society (JLES), published in 2018. The JLES Practice Guideline-Making Committee (PGMC) developed 21 clinical questions (CQs). Methods and Results: A review of these 15 CQs was performed in accordance with the methodology for establishing clinical guidelines. The 15 recommendations for each of these CQs were developed and discussed until consensus by the PGMC was reached. Moreover, outside members who had no involvement in these guidelines evaluated the contents using the Appraisal of Guidelines for Research and Evaluation (AGREE) II reporting checklist. Conclusion: These guidelines have been produced for the adequate management of lymphedema by doctors and other medical staff on the lymphedema management team of medical institutes, including nurses, physical technicians, and occupational therapists.

Breast cancer-related upper limb lymphoedema: an overview

Breast cancer-related lymphoedema can be commonly encountered within a community nurse's role. The severity of lymphoedema can range considerably, from those who are considered 'at risk' due to breast cancer treatment, to individuals with highly complex oedema from advanced disease. This article provides an overview of breast cancer-related lymphoedema, including the risk factors for developing lymphoedema and the impact lymphoedema has physically, psychologically and socially. The treatments for lymphoedema, including clinical practical advice and skills, are presented to support ongoing personal development. A collaborative approach between community nurses and lymphoedema clinics is recommended to ensure that patients receive the best care possible.

High Incidence of Axillary Web Syndrome among Breast Cancer Survivors after Breast Reconstruction

Objective

The aim of this study was to identify if breast reconstruction is a surgical risk factor for axillary web syndrome (AWS) in breast cancer (BC) patients.

Methods

The data of 207 patients who have been diagnosed with unilateral BC and who had mastectomy and lymph node dissection were retrospectively reviewed. Information of their clinical and pathological data, whether they had immediate -reconstruction and intraoperative radiotherapy, surgical methods, and postoperative complications during the 3 months after their surgery (AWS, lymphedema, seroma, and myofascial adhesion) were collected, and the incidence of AWS was compared between different surgical methods.

Results

The overall incidence of AWS was 48.8% in 207 patients. Of the 22 patients who received reconstruction, 19 developed AWS, yielding an incidence of 86%. Multivariate logistic regression modeling showed that patients who underwent reconstruction had a significantly higher incidence of AWS (odds ratio, 4.74), as did patients with postoperative complication of myofascial adhesion (odds ratio, 7.07).

Conclusions

BC survivors after breast reconstruction are susceptible to AWS, and there is a significant association between myofascial adhesion and AWS. Our results can stimulate further investigation and provide an evidence base for the development of educational guidance for patients who plan to undergo breast reconstruction.

Lymphaticovenular anastomosis for breast cancer-related upper extremity lymphedema: a literature review

Breast cancer-related lymphedema is a long-term condition that affects almost half of breast cancer survivors. Clinical studies have looked at the benefits of lymphaticovenular anastomosis (LVA) for the treatment of upper extremities lymphedema after breast cancer, however, there is still controversy if it improves lymphedema. This study aimed to analyze the studies and outcomes related to LVA for breast cancer-related lymphedema. A PubMed/Medline search was performed using "lymphovenous bypass", "upper extremity lymphedema", "arm lymphedema after breast cancer treatment", and "lymphaticovenular anastomosis" as key words. Only English articles reporting outcomes after LVA were included. We found 22 articles that met the inclusion criteria. Positive outcomes were found in 21 studies with an objective volume reduction and subjective symptoms relief after LVA. This literature review concluded that LVA has demonstrated a significant decrease in upper extremity volumes and an improvement in subjectively reporting symptoms in breast cancer-related lymphedema patients.

Lymphoedema After Breast Cancer Treatment is Associated With Higher Body Mass Index: A Systematic Review and Meta-Analysis

Background:

Excess body weight has been identified as an important risk factor for lymphoedema following breast cancer treatment, however it remains unclear how much risk increases as weight increases. We conducted a meta-analysis to assess the relationship between body mass index (BMI) and risk of lymphoedema in breast cancer patients, and to estimate the level of risk by BMI category.

Methods:

We conducted a systematic search of all articles published through May 2018 in PubMed and the Cochrane library. Studies that included data on BMI and lymphoedema in breast cancer patients were included in the meta-analysis. We compared risk of lymphoedema in BMI groups as: BMI<25 versus BMI≥25, BMI<25 versus BMI≥30, BMI≥25 to <30 versus BMI≥30, BMI<30 versus BMI≥30, BMI<25 versus BMI≥25 to BMI<30.

Results:

After exclusion of ineligible studies, 57 studies were included in the meta-analysis. The mean difference in BMI between patients with lymphoedema compared to those without lymphoedema was 1.7 (95% CI, 1.3–2.2). Compared to patients with a BMI<25, risk of lymphoedema was higher in those with a BMI >25 to <30 (odds ratio [OR] 1.3; 95% CI, 1.2 to 1.5), a BMI≥25 (OR 1.7; 95% CI, 1.5 to 1.9), or a BMI≥30 (OR 1.9; 95% CI, 1.6 to 2.4). Compared to patients with a BMI of >25 to <30, risk of lymphoedema was higher in patients with a BMI>30 (OR 1.5; 95% CI,1.4 to 1.8).

Conclusion:

Excess body weight is a risk factor for lymphoedema following treatment of breast cancer, with the magnitude of risk increasing across higher categories of BMI.

Feasibility study of combined dynamic imaging and lymphaticovenous anastomosis surgery for breast cancer-related lymphoedema

BACKGROUND

Breast cancer-related lymphoedema (BCRL) presents a significant healthcare burden and adversely affects quality of life of breast cancer survivors. A prospective feasibility study was performed on lymphaticovenous anastomosis (LVA) for the treatment of BCRL.

METHODS

Patients with BCRL underwent near-infrared spectroscopy with indocyanine green lymphatic mapping to identify suitable lymphatic channels for LVA. End-to-end anastomoses to subdermal venules were performed and patients recommenced compression garment therapy (CGT) after surgery. Volumetric assessment of the affected limb was performed at regular intervals using infrared perometry to calculate the excess volume reduction.

RESULTS

Over a 24-month interval, 27 patients with BCRL underwent LVA. The mean duration of lymphoedema was 3·5 (range 0·5-18) years, and the mean number of LVAs performed was 3 (range 2-5). Twenty-four of the 27 patients completed 12-month follow-up. Patients exhibited three patterns of volumetric response following LVA: sustained response (16 patients), transient response (5) or no response (6). Sustained responders showed an excess volume reduction of -33·2 per cent at 12 months, and this correlated positively with the number of LVAs performed (r = -0·56, P = 0·034). Overall, ten patients were able to downgrade CGT after surgery, and two patients were CGT-free at 12 months.

CONCLUSION

LVA resulted in a sustained volume reduction in selected patients and may offset the burden of CGT. Further work is required to identify biomarkers that predict a favourable response to LVA surgery.