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Deng C, Wu Z, Cai Z, Zheng X, Tang C. Conservative medical intervention as a complement to CDT for BCRL therapy: a systematic review and meta-analysis of randomized controlled trials. Front Oncol 2024; 14:1361128. [PMID: 38737896 PMCID: PMC11082302 DOI: 10.3389/fonc.2024.1361128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Accepted: 04/10/2024] [Indexed: 05/14/2024] Open
Abstract
Background The effect of first-line complex decongestive therapy (CDT) for breast cancer-related lymphedema (BCRL) depending on various factors forces patients to seek additional treatment. Therefore, this meta-analysis was conducted to evaluate the effect of different conservative medical interventions as a complement to CDT. This is the first meta-analysis that includes various kinds of conservative treatments as adjunctive therapy to get broader knowledge and improve practical application value, which can provide recommendations to further improve BCRL patients' health status. Methods RCTs published before 18 December 2023 from PubMed, Embase, Cochrane Library, and Web of Science databases were searched. RCTs that compared the effects of conservative medical intervention were included. A random-effects or fixed-effects model was used based on the heterogeneity findings. Study quality was evaluated using the Cochrane risk of bias tool. Results Sixteen RCTs with 690 participants were included, comparing laser therapy, intermittent pneumatic compression (IPC), extracorporeal shock wave therapy (ESWT), electrotherapy, ultrasound, diet or diet in combination with synbiotic supplement, traditional Chinese medicine (TCM), continuous passive motion (CPM), and negative pressure massage treatment (NMPT). The results revealed that conservative medical intervention as complement to CDT had benefits in improving lymphedema in volume/circumference of the upper extremity [SMD = -0.30, 95% CI = (-0.45, -0.15), P < 0.05, I 2 = 51%], visual analog score (VAS) for pain [SMD = -3.35, 95% CI (-5.37, -1.33), P < 0.05, I 2 = 96%], quality of life [SMD = 0.44, 95% CI (0.19, 0.69), P < 0.05, I 2 = 0], and DASH/QuickDASH [SMD = -0.42, 95% CI (-0.70, -0.14), P < 0.05, I 2 = 10%] compared with the control group. Subgroup analysis revealed that laser therapy and electrotherapy are especially effective (P < 0.05). Conclusion Combining conservative medical interventions with CDT appears to have a positive effect on certain BCRL symptoms, especially laser therapy and electrotherapy. It showed a better effect on patients under 60 years old, and laser therapy of low to moderate intensity (5-24 mW, 1.5-2 J/cm2) and of moderate- to long-term duration (≥36-72 sessions) showed better effects. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=354824, identifier CRD42022354824.
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Affiliation(s)
- Chuyu Deng
- Clinical Medical College of Acupuncture, Moxibustion and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zhiguo Wu
- Clinical Medical College of Acupuncture, Moxibustion and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zijie Cai
- Clinical Medical College of Acupuncture, Moxibustion and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xiaoyan Zheng
- School of Rehabilitation Sciences, Southern Medical University, Guangzhou, China
| | - Chunzhi Tang
- Clinical Medical College of Acupuncture, Moxibustion and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, China
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2
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Klein I, Friger M, David MB, Shahar D. Risk factors for long-term arm morbidities following breast cancer treatments: A systematic review. Oncotarget 2023; 14:921-942. [PMID: 38039404 PMCID: PMC10691815 DOI: 10.18632/oncotarget.28539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 11/16/2023] [Indexed: 12/03/2023] Open
Abstract
PURPOSE To examine the risk factors for arm morbidity following breast cancer treatments, taking a broad view of all types of physical morbidity, including prolonged pain, lymphedema, decreased range of motion, and functional limitations. METHODS A systematic literature review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines. Studies exploring the risk factors for prolonged arm morbidity following breast cancer surgery and treatments were included. The studies were assessed independently according to pre-eligibility criteria, following data extraction and methodological quality assessment. RESULTS 1,242 articles were identified. After removing duplicates, the full texts of 1,153 articles were examined. Sixty-nine of these articles met the criteria and were included in the review. These 69 articles identified 29 risk factors for arm morbidity following treatments for breast cancer. The risk of bias was evaluated using NIH study quality assessment tools. The studies reviewed were published between 2001 and 2021 and included a total of 22,886 patients who were followed up for between three months and 10 years. CONCLUSIONS The main risk factors for long-term morbidity are removal of lymph nodes from the axilla, body mass index >30, having undergone a mastectomy, the stage of the disease, radiation therapy, chemotherapy, infection and trauma to the affected arm after surgery. An understanding of the risk factors for prolonged arm morbidity after surgery can help doctors and therapists in making personalized decisions about the need and timing of rehabilitation treatments.
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Affiliation(s)
- Ifat Klein
- Department of Physical Therapy, Assuta Medical Center, Ramat Hahayal, Tel Aviv 6971028, Israel
- Department of Epidemiology, Biostatistics and Community Health Sciences, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva 8410501, Israel
| | - Michael Friger
- Department of Epidemiology, Biostatistics and Community Health Sciences, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva 8410501, Israel
| | - Merav Ben David
- Department of Physical Therapy, Assuta Medical Center, Ramat Hahayal, Tel Aviv 6971028, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva 8410501, Israel
| | - Danit Shahar
- Department of Epidemiology, Biostatistics and Community Health Sciences, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva 8410501, Israel
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Elumalai T, Jain U, Coles CE, Benson JR. The role of irradiation in the management of the axilla in early breast cancer patients. Front Oncol 2023; 13:1151460. [PMID: 37434967 PMCID: PMC10332143 DOI: 10.3389/fonc.2023.1151460] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 06/06/2023] [Indexed: 07/13/2023] Open
Abstract
The need for axillary radiotherapy in patients with invasive breast cancer (IBC) has been a topic of great debate in the last decade. Management of the axilla has evolved significantly over the past four decades with a trend towards de-escalation of surgical interventions and the aim of reducing morbidity and enhancing QOL without compromising long-term oncology outcomes. This review article will address the role of axillary irradiation with a focus on the omission of completion axillary lymph node dissection in selected patients with sentinel lymph node (SLN) positive early breast cancer (EBC) with reference to current guidelines based on evidence to date.
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Affiliation(s)
- Thiraviyam Elumalai
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambiridge, United Kingdom
| | - Urvashi Jain
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambiridge, United Kingdom
| | - Charlotte E. Coles
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambiridge, United Kingdom
- Department of Oncology, University of Cambridge, Cambiridge, United Kingdom
| | - John R. Benson
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambiridge, United Kingdom
- School of Medicine, Anglia Ruskin University, Cambridge and Chelmsford, Cambiridge, United Kingdom
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Bianchi LMG, Irmici G, Cè M, D'Ascoli E, Della Pepa G, Di Vita F, Casati O, Soresina M, Menozzi A, Khenkina N, Cellina M. Diagnosis and Treatment of Post-Prostatectomy Lymphedema: What's New? Curr Oncol 2023; 30:4512-4526. [PMID: 37232799 DOI: 10.3390/curroncol30050341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/24/2023] [Accepted: 04/24/2023] [Indexed: 05/27/2023] Open
Abstract
Lymphedema is a chronic progressive disorder that significantly compromises patients' quality of life. In Western countries, it often results from cancer treatment, as in the case of post-radical prostatectomy lymphedema, where it can affect up to 20% of patients, with a significant disease burden. Traditionally, diagnosis, assessment of severity, and management of disease have relied on clinical assessment. In this landscape, physical and conservative treatments, including bandages and lymphatic drainage have shown limited results. Recent advances in imaging technology are revolutionizing the approach to this disorder: magnetic resonance imaging has shown satisfactory results in differential diagnosis, quantitative classification of severity, and most appropriate treatment planning. Further innovations in microsurgical techniques, based on the use of indocyanine green to map lymphatic vessels during surgery, have improved the efficacy of secondary LE treatment and led to the development of new surgical approaches. Physiologic surgical interventions, including lymphovenous anastomosis (LVA) and vascularized lymph node transplant (VLNT), are going to face widespread diffusion. A combined approach to microsurgical treatment provides the best results: LVA is effective in promoting lymphatic drainage, bridging VLNT delayed lymphangiogenic and immunological effects in the lymphatic impairment site. Simultaneous VLNT and LVA are safe and effective for patients with both early and advanced stages of post-prostatectomy LE. A new perspective is now represented by the combination of microsurgical treatments with the positioning of nano fibrillar collagen scaffolds (BioBridgeTM) to favor restoring the lymphatic function, allowing for improved and sustained volume reduction. In this narrative review, we proposed an overview of new strategies for diagnosing and treating post-prostatectomy lymphedema to get the most appropriate and successful patient treatment with an overview of the main artificial intelligence applications in the prevention, diagnosis, and management of lymphedema.
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Affiliation(s)
| | - Giovanni Irmici
- Postgraduation School in Radiodiagnostics, University of Milan, 20122 Milan, Italy
| | - Maurizio Cè
- Postgraduation School in Radiodiagnostics, University of Milan, 20122 Milan, Italy
| | - Elisa D'Ascoli
- Postgraduation School in Radiodiagnostics, University of Milan, 20122 Milan, Italy
| | - Gianmarco Della Pepa
- Postgraduation School in Radiodiagnostics, University of Milan, 20122 Milan, Italy
| | - Filippo Di Vita
- Postgraduation School in Plastic Surgery, University of Milan, Via Festa del Perdono, 7, 20122 Milan, Italy
| | - Omar Casati
- Postgraduation School in Plastic Surgery, University of Milan, Via Festa del Perdono, 7, 20122 Milan, Italy
| | - Massimo Soresina
- Plastic Surgery Department, Fatebenefratelli Hospital, ASST Fatebenefratelli Sacco, 20121 Milan, Italy
| | - Andrea Menozzi
- Plastic Surgery Department, Fatebenefratelli Hospital, ASST Fatebenefratelli Sacco, 20121 Milan, Italy
| | - Natallia Khenkina
- Postgraduation School in Radiodiagnostics, University of Milan, 20122 Milan, Italy
| | - Michaela Cellina
- Radiology Department, Fatebenefratelli Hospital, ASST Fatebenefratelli Sacco, 20121 Milan, Italy
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Liu X, Sun K, Yang H, Xia L, Lu K, Meng X, Li Y. Risk factors for the development of severe breast cancer-related lymphedema: a retrospective cohort study. BMC Cancer 2023; 23:361. [PMID: 37081431 PMCID: PMC10116791 DOI: 10.1186/s12885-023-10814-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 04/06/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND Severe lymphedema presents a challenge in terms of treatment due to the significant formation of scar tissue that accompanies it. The aim of this study was to identify intraoperative and preoperative risk factors of severe lymphedema and to develop a nomogram for estimating the risk of severe lymphedema within 3 years of surgery. METHOD Data was collected from a retrospective cohort of 326 patients with BCRL at the Zhejiang Cancer Hospital from November 2015 to November 2018. Univariate and multivariate logistic regression analysis was conducted to identify predictive indicators of severe lymphedema. A nomogram was developed to further improve the clinical applicability. RESULTS In the retrospective cohort, the ratio of severe/non-severe lymphedema within 3 years of surgery was 1:3. Independent risk factors for severe lymphedema were determined to be age, positive lymph nodes, interpectoral (Rotter's) lymph nodes (IPNs) dissection, and educational level. IPNs dissection was found to contribute greatly to the development of severe lymphedema with a higher odds ratio (7.76; 95% CI: 3.87-15.54) than other risk factors. A nomogram was developed by integrating age, positive lymph nodes, IPNs dissection, and educational level, which yielded a C-index of 0.810 and 0.681 in the training and validation cohort, respectively. This suggested a moderate performance of the nomogram in predicting the risk of severe lymphedema within 3 years of surgery. The cut-off values of the low-, medium- and high-risk probabilities were 0.0876 and 0.3498, and the severe lymphedema exhibited a significantly higher risk probability as compared with the non-severe lymphedema. CONCLUSION This study identified the risk factors of severe lymphedema and highlighted the substantial contribution of IPNs dissection to the severity of lymphedema.
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Affiliation(s)
- Xiaozhen Liu
- General Surgery, Cancer center, Department of Breast Surgery, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China
| | - Kewang Sun
- General Surgery, Cancer center, Department of Breast Surgery, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China
| | - Hongjian Yang
- Department of Breast Surgery, Institute of Cancer Research and Basic Medical Sciences of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, 310022, Zhejiang, China
| | - Lingli Xia
- Department of Breast Surgery, Institute of Cancer Research and Basic Medical Sciences of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, 310022, Zhejiang, China
| | - Kefeng Lu
- Department of outpatient service, Institute of Cancer Research and Basic Medical Sciences of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, 310022, Zhejiang, China
- Cancer center, Department of Ultrasound Medicine, Affiliated People's Hospital, Zhejiang Provincial People's Hospital, Hangzhou Medical college), Hangzhou, 310014, Zhejiang, China
| | - Xuli Meng
- General Surgery, Cancer center, Department of Breast Surgery, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China
| | - Yongfeng Li
- General Surgery, Cancer center, Department of Breast Surgery, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China.
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Noguchi M, Inokuchi M, Yokoi-Noguchi M, Morioka E, Haba Y. Conservative axillary surgery is emerging in the surgical management of breast cancer. Breast Cancer 2023; 30:14-22. [PMID: 36342647 DOI: 10.1007/s12282-022-01409-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 10/12/2022] [Indexed: 11/09/2022]
Abstract
Axillary lymph node dissection (ALND) has been the standard axillary treatment for breast cancer for a long time. However, ALND is associated with postoperative morbidities, including local sensory dysfunction, reduced shoulder mobility and most notably arm lymphedema. Recently, ALND can be avoided not only in clinically node-negative (cN0) patients with negative sentinel lymph nodes (SLNs), but also in patients with less than 3 positive SLNs receiving breast radiation, axillary radiation, or a combination of the two. Moreover, SLN biopsy has been adopted for use in clinically node-positive (cN +) patients presenting as cN0 after neoadjuvant chemotherapy (NAC); ALND may be avoided in cN + patients who convert to SLN-negative following NAC. Patients who undergo SLN biopsy alone have less postsurgical morbidities than those who undergo ALND. Nevertheless, ALND is still required in a select group of patients. A variety of conservative approaches to ALND have been developed to spare arm lymphatics to minimize arm lymphedema. These conservative procedures seem to decrease the incidence of lymphedema without increasing axillary recurrence. In the era of effective multimodality therapy, full conventional ALND removing all microscopic axillary disease may now be unnecessary in both cN0 patients and cN + patients. Regardless, emerging procedures for ALND should still be considered as investigational approaches, as further studies with longer follow-up are necessary to determine the safety of conservative ALND to spare arm lymphatics.
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Affiliation(s)
- Masakuni Noguchi
- Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan. .,Breast Center, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan.
| | - Masafumi Inokuchi
- Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan.,Breast Center, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan
| | - Miki Yokoi-Noguchi
- Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan.,Breast Center, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan
| | - Emi Morioka
- Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan.,Breast Center, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan
| | - Yusuke Haba
- Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan.,Breast Center, Kanazawa Medical University Hospital, Daigaku 1-1, Kahoku, Uchinada, Ishikawa, 920-0293, Japan
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Ridner SH, Dietrich MS, Boyages J, Koelmeyer L, Elder E, Hughes TM, French J, Ngui N, Hsu J, Abramson VG, Moore A, Shah C. A Comparison of Bioimpedance Spectroscopy or Tape Measure Triggered Compression Intervention in Chronic Breast Cancer Lymphedema Prevention. Lymphat Res Biol 2022; 20:618-628. [PMID: 35099283 PMCID: PMC9810346 DOI: 10.1089/lrb.2021.0084] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Background: This study compared rates of progression to chronic breast cancer-related lymphedema (defined as ≥ 10% arm volume change from baseline requiring complex decongestive physiotherapy [CDP]) following an intervention for subclinical lymphedema (S-BCRL) triggered by bioimpedance spectroscopy (BIS) or by tape measurement (TM). Methods and Results: This stratified, randomized, international trial enrolled new breast cancer patients undergoing: mastectomy/partial mastectomy, axillary treatment (dissection, sentinel lymph node biopsy [SLNB] >6 nodes or radiation), radiation therapy (chest wall/breast, supraclavicular fossa), or taxane-based chemotherapy. Following postsurgery eligibility reassessment, centralized, 1:1 randomization to prospective surveillance by BIS or TM occurred. S-BCRL detection triggered a 4-week, 12-hour per day, compression sleeve, and gauntlet intervention. The primary outcome (n = 209), rates of postintervention progression to CDP, was assessed over 3 years. Between June 24, 2014 and September 11, 2018, 1200 patients were enrolled, 963 randomized (BIS n = 482; TM n = 481) and 879 analyzed (BIS n = 442; TM n = 437). Median follow-up was 32.9 months (interquartile range = 22, 35). BIS patients triggered an intervention at a lower rate than TM patients (20.1%, n = 89 vs. 27.5%, n = 120, p = 0.011). Median months to trigger were longer with BIS than TM (9.7; 95% confidence interval [CI], 8.2-12.6 vs. 3.9; 95% CI, 2.8-4.5, p = 0.001). Overall, 14.4% (n = 30) progressed post-intervention, with reduced likelihood for BIS patients than TM patients (7.9%, n = 7 vs. 19.2%, n = 23; relative risk = 0.41; 95% CI, 0.13-0.81; absolute reduction 11.3%; 95% CI, 2.3-20.3; p = 0.016). Conclusions: Compared to TM, BIS provides a more precise identification of patients likely to benefit from an early compression intervention. Clinical Trial Registration number: NCT02167659.
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Affiliation(s)
- Sheila H. Ridner
- Vanderbilt University School of Nursing, Nashville, Tennessee, USA.,Address correspondence to: Sheila H. Ridner, PhD, RN, FAAN, Vanderbilt University School of Nursing, 461 21st Avenue South, Nashville, TN 37240, USA
| | - Mary S. Dietrich
- Vanderbilt University School of Nursing, Nashville, Tennessee, USA.,Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - John Boyages
- Australian Lymphoedema Education, Research, and Treatment Program, Macquarie University, Macquarie Park, Australia.,Department of Clinical Medicine, Macquarie University, Macquarie Park, Australia.,Medicine, Health & Human Sciences, ICON Cancer Center, Wahroonga, Australia
| | - Louise Koelmeyer
- Australian Lymphoedema Education, Research, and Treatment Program, Macquarie University, Macquarie Park, Australia.,Department of Clinical Medicine, Macquarie University, Macquarie Park, Australia
| | - Elisabeth Elder
- Westmead Breast Cancer Institute, Westmead Hospital, Westmead, Australia.,The University of Sydney, Sydney, Australia.,Lakeside Specialist Breast Clinic, Lakeview Private Hospital, Norwest, Australia
| | - T. Michael Hughes
- Northern Surgical Oncology, Sydney Adventist Hospital, Wahroonga, Australia.,Sydney Adventist Hospital Clinical School, College of Health and Medicine, Australian National University, Acton, Australia
| | - James French
- Westmead Breast Cancer Institute, Westmead Hospital, Westmead, Australia.,The University of Sydney, Sydney, Australia.,Lakeside Specialist Breast Clinic, Lakeview Private Hospital, Norwest, Australia
| | - Nicholas Ngui
- Northern Surgical Oncology, Sydney Adventist Hospital, Wahroonga, Australia
| | - Jeremy Hsu
- Department of Clinical Medicine, Macquarie University, Macquarie Park, Australia.,Westmead Breast Cancer Institute, Westmead Hospital, Westmead, Australia.,The University of Sydney, Sydney, Australia
| | - Vandana G. Abramson
- Division of Hematology/Oncology, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, USA
| | - Andrew Moore
- Southeast Cancer Center, Cape Girardeau, Missouri, USA
| | - Chirag Shah
- Cleveland Clinic, Taussig Cancer Institute, Cleveland, Ohio, USA
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Alsumai TS, Alhazzaa N, Alshamrani A, Assiri S, Alhefdhi A. Factors Predicting Positive Sentinel Lymph Node Biopsy in Clinically Node-Negative Breast Cancer. BREAST CANCER (DOVE MEDICAL PRESS) 2022; 14:323-334. [PMID: 36237483 PMCID: PMC9553108 DOI: 10.2147/bctt.s373005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 09/22/2022] [Indexed: 11/06/2022]
Abstract
Purpose Sentinel lymph node (SLN) biopsy (SLNB) is the standard tool to stage the axilla of breast cancer patients. This study aimed to identify the predictors of positive SLNB in patients with clinically node-negative breast cancer. Patients and Methods A retrospective, single-institution cohort of patients with early-stage breast cancer without clinically identifiable axillary lymphadenopathy was chosen from January 2010 to December 2018. Logistic regression was used to identify possible predictors of positive SLNB. Results Four hundred and seventy patients were identified; their mean age was 50±11 years. Most patients had the following characteristics: invasive ductal carcinoma (n=382, 81.3%), unilateral tumor (n=461, 98.1%), unifocal disease (n=351, 74.7%), intermediate grade (n=276, 59.0%), and estrogen and progesterone receptor positivity with human epidermal growth factor receptor 2 negativity (n=305, 64.9%). The mean size of the breast mass was 2.3±1.5 cm. SLNB was positive in 128 (27.2%) cases. The mean number of SLNs was 2±1.2. Axillary lymph node dissection was performed in 109 patients. The mean number of lymph nodes removed was 15±6. In 66 (60.6%) of the 109 patients with metastatic axillary nodes, only the SLNs were found to be positive. The number of SLNs, tumor size, tumor grade, receptor status, prominent axillary lymph nodes, and lymphovascular invasion predicted positive SLNB (P = 0.01, 0.03, 0.03, and 0.04 and <0.001 and <0.001, respectively). Conclusion Our results suggest that a number of histopathological and radiological characteristics of breast cancer can predict SLNB positivity in clinically node-negative breast cancer patients.
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Affiliation(s)
- Thuraya S Alsumai
- Department of Surgery, Section of Breast & Endocrine Surgery, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia,Correspondence: Thuraya S Alsumai, Department of Surgery, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia, Tel +966 565433996, Email
| | - Norah Alhazzaa
- Department of Surgery, Section of Breast & Endocrine Surgery, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | | | - Sarah Assiri
- Department of Surgery, Section of Breast & Endocrine Surgery, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Amal Alhefdhi
- Department of Surgery, Section of Breast & Endocrine Surgery, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia,Faculty of Medicine, Alfaisal University, Riyadh, Saudi Arabia
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Tramacere F, Arcangeli S, Colciago RR, Lucchini R, Pati F, Portaluri M. Outcomes and toxicity following post-operative hypofractionated radiotherapy to the regional nodes and the breast or the chest wall in locally advanced breast cancer. Br J Radiol 2022; 95:20211299. [PMID: 35522785 DOI: 10.1259/bjr.20211299] [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: 11/05/2022] Open
Abstract
OBJECTIVES We aimed to analyze the impact of a 3-week schedule of HypoFractionated (HF) radiotherapy (RT) after axillary dissection and breast surgery, in terms of safety and efficacy in patients with locally advanced breast cancer (BC). METHODS Eligible patients were females with Stage IIA - IIIC BC who underwent axillary dissection and breast surgery, either quadrantectomy or mastectomy. HF RT was delivered in 15 or 16 fractions for a total dose of 40.05 Gy or 42.56 Gy, respectively, to the clavicular nodal region along with the whole breast (HF WBRT) or the chest wall (HF PMRT), according to the type of surgery. Locoregional recurrence (LRR), distant metastases-free survival (DMFS), overall survival (OS) and acute and late treatment-related toxicities were estimated. RESULTS 57 patients with a median age of 60 years (32-85) were retrospectively analyzed. 34 (60%) of patients underwent breast conservative surgery in the form of quadrantectomy and 23 (40%) were offered radical mastectomy. All patients underwent hypofractionated regional nodal irradiation (HF RNI). 34 (60%) of them underwent HF WBRT, while 23 (40%) received HF PMRT.At a median follow-up of 80 months (30-113), the 7-year LRR-free survival was 93% (95% CI, 74%-95%). The same features for DMFS and OS were 76% (95% CI, 52%-78%) and 67% (95% CI, 50%-80%), respectively. Only one (2%) patient experienced G3 acute skin toxicity. No grade ≥2 late toxicity was observed. CONCLUSION Our study shows that HF RNI with HF RT to the whole breast or the chest wall after breast surgery is safe and effective in patients with locally advanced BC. Longer follow-up is needed to strengthen further analyses on late toxicity and clinical outcomes. ADVANCES IN KNOWLEDGE This paper adds to the evidence that post-operative RNI with WBRT or PMRT can be safely and effectively delivered with 3-week HF regimen. Locally advanced BC patients can be offered HF RT to the regional nodes and the breast or the chest wall regardless the type of surgery.
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Affiliation(s)
| | - Stefano Arcangeli
- Department of Radiation Oncology, School of Medicine and Surgery - University of Milan Bicocca, Milan, Italy
| | - Riccardo Ray Colciago
- Department of Radiation Oncology, School of Medicine and Surgery - University of Milan Bicocca, Milan, Italy
| | - Raffaella Lucchini
- Department of Radiation Oncology, School of Medicine and Surgery - University of Milan Bicocca, Milan, Italy
| | - Francesca Pati
- Department of Radiation Oncology, ASL A. Perrino, Brindisi, Italy
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Gradishar WJ, Moran MS, Abraham J, Aft R, Agnese D, Allison KH, Anderson B, Burstein HJ, Chew H, Dang C, Elias AD, Giordano SH, Goetz MP, Goldstein LJ, Hurvitz SA, Isakoff SJ, Jankowitz RC, Javid SH, Krishnamurthy J, Leitch M, Lyons J, Mortimer J, Patel SA, Pierce LJ, Rosenberger LH, Rugo HS, Sitapati A, Smith KL, Smith ML, Soliman H, Stringer-Reasor EM, Telli ML, Ward JH, Wisinski KB, Young JS, Burns J, Kumar R. Breast Cancer, Version 3.2022, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2022; 20:691-722. [PMID: 35714673 DOI: 10.6004/jnccn.2022.0030] [Citation(s) in RCA: 363] [Impact Index Per Article: 181.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The therapeutic options for patients with noninvasive or invasive breast cancer are complex and varied. These NCCN Clinical Practice Guidelines for Breast Cancer include recommendations for clinical management of patients with carcinoma in situ, invasive breast cancer, Paget disease, phyllodes tumor, inflammatory breast cancer, and management of breast cancer during pregnancy. The content featured in this issue focuses on the recommendations for overall management of ductal carcinoma in situ and the workup and locoregional management of early stage invasive breast cancer. For the full version of the NCCN Guidelines for Breast Cancer, visit NCCN.org.
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Affiliation(s)
| | | | - Jame Abraham
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | - Rebecca Aft
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | - Doreen Agnese
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | | | | | | | - Chau Dang
- Memorial Sloan Kettering Cancer Center
| | | | | | | | | | | | | | | | - Sara H Javid
- Fred Hutchinson Cancer Research Center/University of Washington
| | | | | | - Janice Lyons
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | | | | | | | - Hope S Rugo
- UCSF Helen Diller Family Comprehensive Cancer Center
| | | | | | | | | | | | | | - John H Ward
- Huntsman Cancer Institute at the University of Utah
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11
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Chun MJ, Saeg F, Meade A, Kumar T, Toraih EA, Chaffin AE, Homsy C. Immediate Lymphatic Reconstruction for Prevention of Secondary Lymphedema: A Meta-Analysis. J Plast Reconstr Aesthet Surg 2021; 75:1130-1141. [PMID: 34955392 DOI: 10.1016/j.bjps.2021.11.094] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 11/06/2021] [Accepted: 11/14/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Secondary lymphedema remains one of the most notorious complications of axillary and pelvic lymph node surgery following mastectomy. There is a lack of high-level evidence found on the effectiveness of immediate lymphatic reconstruction (ILR) in preventing secondary lymphedema. This meta-analysis evaluates the outcomes of ILR for prevention of secondary lymphedema in patients undergoing different surgeries, and provides suggestions for lymphatic microsurgical preventive healing approach (LYMPHA). METHODS A review of PubMed, Embase, and Web of Science was performed according to Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. All English-language studies published from January 1, 2009 to June 1, 2020 were included. We excluded non-ILR interventions, literature reviews/letters/commentaries, and nonhuman or cadaver studies. A total of 789 patients that were enrolled in 13 studies were included in our one-arm meta-analysis. RESULTS A total of 13 studies (n=789) met inclusion criteria: upper extremity ILR (n=665) and lower extremity ILR (n=124). The overall incidence of lymphedema for upper extremity ILR was 2.7% (95%CI: 1.1%-4.4%) and lower extremity ILR was 3.6% (95%CI: 0.3%-10.1%). For upper extremity ILR, the average follow-up time was 11.6 ± 7.8 months and the LE incidence appeared to be the highest approximately 1 to 2 years postoperation. CONCLUSIONS Lymphedema is a common complication in cancer treatment. ILR, especially LYMPHA, may be an effective technique to facilitate lymphatic drainage at the time of the index procedure but future studies will be required to show its short-term efficacy and long-term outcomes.
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Affiliation(s)
- Magnus J Chun
- Division of Plastic and Reconstructive Surgery, Tulane University School of Medicine, New Orleans, LA, 70112
| | - Fouad Saeg
- Division of Plastic and Reconstructive Surgery, Tulane University School of Medicine, New Orleans, LA, 70112
| | - Anna Meade
- Department of Plastic Surgery, University of Texas-Southwestern, Dallas, TX, 75390
| | - Taruni Kumar
- Division of Plastic and Reconstructive Surgery, Tulane University School of Medicine, New Orleans, LA, 70112
| | - Eman A Toraih
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, 70112; Department of Histology and Cell Biology, Genetics Unit, Faculty of Medicine, Suez Canal University, Ismailia, 41522, Egypt
| | - Abigail E Chaffin
- Division of Plastic and Reconstructive Surgery, Tulane University School of Medicine, New Orleans, LA, 70112
| | - Christopher Homsy
- Division of Plastic and Reconstructive Surgery, Tufts Medical Center, Boston, MA, 02111.
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12
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Sentinel Lymph Node Positive Rate Predicts Non-Sentinel Lymph Node Metastasis in Breast Cancer. J Surg Res 2021; 271:59-66. [PMID: 34839110 DOI: 10.1016/j.jss.2021.09.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 09/09/2021] [Accepted: 09/22/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND To investigate retrospectively an association between the number of metastatic sentinel lymph nodes (SLNs) per total number of SLNs per patient (i.e., the SLN positive rate, or SLN-PR) and non-SLN metastasis in breast cancer. METHODS A large population (n = 2250) underwent SLN dissection from January 1, 2014 to January 1, 2020; 627 (27.87%) had at least one positive SLN (SLN+). Among these, 283 underwent axillary lymph node (ALN) dissection, and formed the test group. Four external validation groups comprised 43 patients treated in 2019. SLN mappings were examined using methylene blue and indocyanine green. Lymph node ultrasound, SLN-PR, and pathological characteristics were compared between patients with and without non-SLN metastasis. An SLN-PR cutoff value was calculated using receiver operating characteristic (ROC) curves. Associations between clinicopathological variables and SLN-PR with non-SLN metastasis were analyzed by multivariate logistic regression model. RESULTS The median age was 47 years (IQR: 42-56 y). The median number of resected SLNs was 4. Patients with positive non-SLNs (126/283, 44.52%) had a median of 2 positive node. SLN-PR > 0.333 was a risk factor for non-SLN positivity (area under the ROC curve, 0.726); and carried significantly higher risk of non-SLN metastasis (P < 0.001). This was validated in the external group. CONCLUSIONS SLN-PR > 0.333 was associated with greater risk of non-SLN metastasis. This provides a reference to non-SLN metastasis in patients with SLN metastasis, an indication for ALN dissection and choice of adjuvant treatment.
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Omar MTA, Gwada RFM, Omar GSM, El-Sabagh RM, Mersal AEAE. Low-Intensity Resistance Training and Compression Garment in the Management of Breast Cancer-Related Lymphedema: Single-Blinded Randomized Controlled Trial. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2020; 35:1101-1110. [PMID: 31243692 DOI: 10.1007/s13187-019-01564-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
There is limited evidence regarding the combined effect of exercise and compression garment on breast cancer-related lymphedema (BCRL). Therefore, we investigate the effect of low-intensity resistance training alone or in combination with a compression garment on lymphedema volume, self-reported lymphedema symptoms, and shoulder mobility and function. A total of 60 women with unilateral BCRL were randomly assigned to low-intensity resistance exercises (Rex group, n = 30) or exercises and compression garment (Rex-Com-group, n = 30). Both groups take part in exercises program consisted of 10-12 repetitions at 50 to 60% of one repetition maximum (IRM), three times weekly, for 8 weeks. The primary outcome was lymphedema volume determined by percentage reduction of excess limb volume (ELV). Secondary outcomes were lymphedema symptoms (pain, heaviness, and tightness) and shoulder mobility and function using the disabilities of the arm, shoulder, and hand (DASH) questionnaire. All measurements were standardized and performed before (week 0, W0), after the intervention (week 8, W8), and at follow-up (week 12, W12). A significant reduction in percentage of ELV (p < 0.01), pain severity (p < 0.05), a sensation of heaviness (p < 0.05) and tightness (p < 0.001), and improvement in shoulder range of motion (p < 0.05) and function on DASH scores (p < 0.05) were observed at W8 and W12 in both groups. However, no between-group differences were observed over time. These findings suggest that low-intensity resistance training, irrespective of garment use, can effectively reduce limb volume and lymphedema symptoms, and increase shoulder mobility and function.
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Affiliation(s)
- Mohammed T A Omar
- Physical Therapy Department for Surgery, Faculty of Physical Therapy, Cairo University, 7 Ahmad Al-Zayat St., Bain El-Sarayat, Giza, 12612, Egypt.
| | - Rehab F M Gwada
- Physical Therapy Department, National Heart Institute, Giza, Egypt
| | - Ghada S M Omar
- Physical Therapy Department for Surgery, Faculty of Physical Therapy, Cairo University, 7 Ahmad Al-Zayat St., Bain El-Sarayat, Giza, 12612, Egypt
- Physical Therapy Department, Faculty of Health, University College Copenhagen, Copenhagen, Denmark
| | - Rokia M El-Sabagh
- Physical Therapy Department, El-Mattaria Teaching Hospital, Cairo, Egypt
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14
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Disparities in the Use of Sentinel Lymph Node Dissection for Early Stage Breast Cancer. J Surg Res 2020; 254:31-40. [PMID: 32408028 DOI: 10.1016/j.jss.2020.03.063] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 03/11/2020] [Accepted: 03/26/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Clinical trials have long established the long-term safety of omitting axillary lymph node dissection (ALND) after sentinel lymph node dissection (SLND) in patients with clinically node-negative early stage breast cancer. The variations in utilization of SLND and ALND in this patient population, however, are currently unknown. METHODS Adult female patients (40 years and older) within the National Cancer Database diagnosed with breast cancer between January 2013 and December 2015, who had clinical T1-T2 and N0 disease, and who underwent either SLND (with or without subsequent ALND) or ALND were included. Differences in utilization across race, ethnicity, insurance type, facility, and residential characteristics were assessed using multivariable logistic regression. RESULTS Overall, 271,689 patients were included, of which 26,527 (10%) received ALND and 245,162 (90%) underwent SLND. After adjusting for demographics and cancer characteristics, black (odds ratio [OR], 1.11; 95% confidence interval [95% CI], 1.06-1.17) and Hispanic women (OR, 1.16; 95% CI, 1.10-1.24) were more likely to receive ALND. Patients without health insurance (OR, 1.33; 95% CI, 1.19-1.47), compared with private health insurance, and those receiving treatment at community cancer centers (OR, 1.60; 95% CI, 1.53-1.67), compared with academic/research centers, were also more likely to receive ALND. CONCLUSIONS Although the vast majority of women undergo SLND, significant disparities exist in its utilization for early stage breast cancer, with traditionally underserved patients receiving unwarranted extensive axillary surgery. Increased patient and surgeon education is needed to decrease variations in care that can affect patient's quality of life.
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15
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Kanda MH, da Costa Vieira RA, Lima JPSN, Paiva CE, de Araujo RLC. Late locoregional complications associated with adjuvant radiotherapy in the treatment of breast cancer: Systematic review and meta-analysis. J Surg Oncol 2019; 121:766-776. [PMID: 31879978 DOI: 10.1002/jso.25820] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 12/14/2019] [Indexed: 02/06/2023]
Abstract
This systematic review with meta-analysis addressed late locoregional complications associated with adjuvant radiotherapy (RT) in breast cancer. Among 2120 titles, ten comparative studies in patients undergoing surgery vs surgery and radiotherapy reporting complications were evaluated. RT was associated with an increased risk of capsular contracture and decreased the mobility of the upper limb. A borderline association of lymphedema risk using RT was noted in the random-effects model but was significant in the fixed-effects model.
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Affiliation(s)
- Márcia Helena Kanda
- Programa de Pós-Graduação em Oncologia, Hospital de Câncer de Barretos, Barretos, São Paulo, Brasil.,Departamento de Oncologia Clínica do Hospital de Câncer de Barretos, São Paulo, Brasil
| | - René Aloisio da Costa Vieira
- Programa de Pós-Graduação em Oncologia, Hospital de Câncer de Barretos, Barretos, São Paulo, Brasil.,Programa de Pós-Graduação em Ginecologia, Obstetricia e Mastologia, Faculdade de Medicina de Botucatu. UNESP, Botucatu, São Paulo, Brasil
| | - João Paulo S N Lima
- Departamento de Oncologia Clínica e Laboratório de Bioinformática, A.C. Camargo Cancer Center, São Paulo, São Paulo, Brazil
| | - Carlos Eduardo Paiva
- Programa de Pós-Graduação em Oncologia, Hospital de Câncer de Barretos, Barretos, São Paulo, Brasil.,Departamento de Oncologia Clínica do Hospital de Câncer de Barretos, São Paulo, Brasil
| | - Raphael Leonardo Cunha de Araujo
- Programa de Pós-Graduação em Oncologia, Hospital de Câncer de Barretos, Barretos, São Paulo, Brasil.,Departamento de Cirurgia do Aparelho Digestivo, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil.,Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
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Gross JP, Lynch CM, Flores AM, Jordan SW, Helenowski IB, Gopalakrishnan M, Cutright D, Donnelly ED, Strauss JB. Determining the Organ at Risk for Lymphedema After Regional Nodal Irradiation in Breast Cancer. Int J Radiat Oncol Biol Phys 2019; 105:649-658. [DOI: 10.1016/j.ijrobp.2019.06.2509] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 06/14/2019] [Accepted: 06/17/2019] [Indexed: 10/26/2022]
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17
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Lim SM, Han Y, Kim SI, Park HS. Utilization of bioelectrical impedance analysis for detection of lymphedema in breast Cancer survivors: a prospective cross sectional study. BMC Cancer 2019; 19:669. [PMID: 31286884 PMCID: PMC6613266 DOI: 10.1186/s12885-019-5840-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Accepted: 06/17/2019] [Indexed: 11/28/2022] Open
Abstract
Background Breast cancer survivors are at risk of developing breast cancer-related lymphedema (BCRL) after surgical treatment, which may have a negative effect on quality of life. The purpose of this study was to investigate the clinical role of bioelectrical impedance analysis (BIA) and the relationship between the development of BCRL in breast cancer survivors who have undergone axillary surgery. Methods A total of 228 patients with breast cancer were enrolled in the study between May 2016 and January 2017. BCRL was assessed by measuring the circumference of both arms at 15 cm below the acromion process and the olecranon process. Patients were classified as BCRL (n = 22) and non-BCRL (n = 206) based on the difference of the arm circumference of 2 cm. Data including lymphedema, anthropometry, BIA measurements, food frequency questionnaire, type of surgery, total number of dissected lymph nodes, and post-operative treatment were collected. Results Of the breast cancer survivors, 10.4% had BCRL by the definition. The BCRL group contained 22 patients, while the non-BCRL group contained 206 patients. Compared to the non-BCRL group, the BCRL group had a higher body mass index, a larger percentage of ideal body weight, more dissected lymph nodes, and higher single frequency BIA (SFBIA) ratio (P = 0.027, P = 0.031, P < 0.001, and P < 0.001, respectively). The SFBIA ratio provided 63.64% sensitivity and 95.15% specificity in estimating the risk of BCRL. Conclusion Our data provides evidence to support that the use of SFBIA ratio can serve as an alternative method to monitor and/or diagnose BCRL. Trial registration This trial was retrospectively registered at Clinicaltrials.gov identifier (NCT03391206) on the 5 January 2018.
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Affiliation(s)
- Sung Mook Lim
- Department of Surgery, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Yujin Han
- Department of Food and Nutrition, College of Human Ecology, Yonsei University, 50, Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Seung Il Kim
- Department of Surgery, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Hyung Seok Park
- Department of Surgery, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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18
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Development and Validation of a Nomogram to Predict Lymphedema After Axillary Surgery and Radiation Therapy in Women With Breast Cancer From the NCIC CTG MA.20 Randomized Trial. Int J Radiat Oncol Biol Phys 2019; 105:165-173. [PMID: 31085285 DOI: 10.1016/j.ijrobp.2019.05.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 05/02/2019] [Accepted: 05/07/2019] [Indexed: 01/10/2023]
Abstract
PURPOSE Regional nodal irradiation for women with breast cancer is known to be an important risk factor for the development of upper extremity lymphedema, but tools to accurately predict lymphedema risks for individual patients are lacking. This study sought to develop and validate a nomogram to predict lymphedema risk after axillary surgery and radiation therapy in women with breast cancer. METHODS AND MATERIALS Data from 1832 women accrued on the MA.20 trial between March 2000 and February 2007 were used to create a prognostic model with National Cancer Institute Common Toxicity Criteria Version 2.0 grade 2 or higher lymphedema as the primary endpoint. Multivariable logistic regression estimated model performance. External validation was performed on data from a single large academic cancer center (N = 785). RESULTS In the MA.20 trial cohort, 3 risk factors were predictive of lymphedema risk: body mass index (adjusted odds ratio, 1.05 per unit body mass index; 95% confidence interval [CI], 1.03-1.08, P < .001), extent of axillary surgery (adjusted odds radio for 8-11 lymph nodes removed, 3.28 [95% CI, 1.53-7.89] P = .004; 12-15 lymph nodes, 4.04 [95% CI, 1.76-10.26] P = .002; ≥16 nodes, 5.08 [95% CI, 2.26-12.70] P < .001), and extent of nodal irradiation (adjusted odds radio for limited, 1.66 [95% CI, 1.08-2.56] P = .02; for extensive, 2.31 [95% CI, 1.28-4.10] P = .004). A nomogram was created from these data that predicted lymphedema risk with reasonable accuracy confirmed by both internal (concordance index, 0.69; 95% CI, 0.64-0.74) and external validation (concordance index, 0.71; 95% CI, 0.66-0.76). CONCLUSIONS The nomogram created from the MA.20 randomized trial data using clinical information may be useful for lymphedema screening and risk stratification for therapeutic intervention trials.
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19
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Breast Cancer-Related Lymphedema—a Case of the Left Upper Arm Lymphedema After Modified Radical Mastectomy Presenting with Nonfunctional Limb. Indian J Surg 2019. [DOI: 10.1007/s12262-018-1808-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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20
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Pervane Vural S, Ayhan FF, Duyur Cakit B, Soran A. Bone loss in the affected forearm in patients with breast cancer-related lymphedema: a controlled study. Support Care Cancer 2018; 27:2545-2551. [DOI: 10.1007/s00520-018-4541-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 11/04/2018] [Indexed: 10/27/2022]
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21
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Radiation Therapy Field Design and Lymphedema Risk After Regional Nodal Irradiation for Breast Cancer. Int J Radiat Oncol Biol Phys 2018; 102:71-78. [DOI: 10.1016/j.ijrobp.2018.03.046] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 03/11/2018] [Accepted: 03/26/2018] [Indexed: 11/18/2022]
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22
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Gregorowitsch ML, Verkooijen HM, Houweling A, Fuhler N, Koelemij R, Schoenmaeckers EJP, Sier MF, Ernst MF, Witkamp AJ, Van Dalen T, Young-Afat DA, van den Bongard DHJG. Impact of modern-day axillary treatment on patient reported arm morbidity and physical functioning in breast cancer patients. Radiother Oncol 2018; 131:221-228. [PMID: 30033384 DOI: 10.1016/j.radonc.2018.07.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 06/28/2018] [Accepted: 07/04/2018] [Indexed: 01/23/2023]
Abstract
PURPOSE To reduce arm morbidity, routine axillary lymph node dissection (ALND) is often omitted or replaced by axillary radiotherapy (AxRT) in patients with limited nodal involvement. We evaluated patient-reported arm morbidity and physical functioning in breast cancer patients undergoing modern-day axillary treatment. METHODS All patients within the UMBRELLA cohort undergoing local radiotherapy with sentinel lymph node biopsy (SLNB), ALND and/or AxRT were selected. Patient-reported arm morbidity and physical functioning were assessed with EORTC QLQ C30/BR23 questionnaires up to eighteen months after initiation of radiotherapy. Patient-reported outcomes were compared between patients with SLNB only, ALND only, AxRT (level I-II), AxRT (level I-IV) or AxRT plus ALND by means of mixed model analysis. RESULTS In total, 949 patients were identified; 641 (68%) SLNB only, 57 (6%) ALND only, 94 (10%) AxRT level I-II, 72 (8%) AxRT level I-IV and 85 (9%) ALND + AxRT. SLNB only resulted in the least arm morbidity scores. ALND + AxRT resulted in most arm morbidity, with clinically relevant differences at 18 months. AxRT (level I-II or level I-IV) resulted in significantly less arm symptoms in the first 3 months compared to ALND. Arm symptom scores between those receiving AxRT on levels I-II and I-IV were similar. CONCLUSION Of all axillary management strategies, ALND plus AxRT is associated with worst patient-reported outcomes. AxRT resulted in less arm morbidity compared to ALND. Selective radiotherapy treatment of the axilla, i.e. radiotherapy of levels I-II only instead of levels I-IV, did not lead to clinically relevant reduced arm morbidity.
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Affiliation(s)
| | - Helena M Verkooijen
- Imaging Division, University Medical Center Utrecht, Utrecht, The Netherlands; University of Utrecht, The Netherlands
| | - Anette Houweling
- Department of Radiation Oncology, University Medical Center, Utrecht, The Netherlands
| | - Nick Fuhler
- Department of Radiation Oncology, University Medical Center, Utrecht, The Netherlands
| | - Ron Koelemij
- Department of Surgery, St. Antonius, Nieuwegein, The Netherlands
| | | | - Maartje F Sier
- Department of Surgery, Ziekenhuis Rivierenland, Tiel, The Netherlands
| | - Miranda F Ernst
- Department of Surgery, Alexander Monro Clinics, Bilthoven, The Netherlands
| | - Arjen J Witkamp
- Department of Surgery, University Medical Center Utrecht, The Netherlands
| | - Thijs Van Dalen
- Department of Surgery, Diakonessenhuis, Utrecht, The Netherlands
| | - Danny A Young-Afat
- Imaging Division, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, The Netherlands
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23
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Kilgore LJ, Korentager SS, Hangge AN, Amin AL, Balanoff CR, Larson KE, Mitchell MP, Chen JG, Burgen E, Khan QJ, O'Dea AP, Nye L, Sharma P, Wagner JL. Reducing Breast Cancer-Related Lymphedema (BCRL) Through Prospective Surveillance Monitoring Using Bioimpedance Spectroscopy (BIS) and Patient Directed Self-Interventions. Ann Surg Oncol 2018; 25:2948-2952. [PMID: 29987599 DOI: 10.1245/s10434-018-6601-8] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Breast cancer-related lymphedema (BCRL) is a chronic progressive disease that results from breast cancer treatment and nodal surgery. NCCN guidelines support baseline measurements with prospective assessment for early diagnosis and treatment. We sought to determine if baseline measurement with bioimpedance spectroscopy (BIS) and serial postoperative evaluations provide early detection amenable to conservative interventions that reduce BCRL. METHODS Breast cancer patients with unilateral disease high-risk for BCRL from a single institution were evaluated from November 2014 to December 2017. High risk was defined as axillary lymph node dissection with radiation and/or taxane chemotherapy. Patients received preoperative baseline BIS measurements followed by postoperative measurements with at least two follow-ups. Patients with BIS results that were 2 standard deviations above baseline (10 + points) started home conservative interventions for 4-6 weeks. Postintervention measurements were taken to assess improvement. RESULT A total of 146 patients high-risk for BCRL were included. Forty-nine patients (34%) developed early BCRL and started self-directed treatment. Forty patients (82%) had elevated BIS measurements return to normal baseline range. Nine (6%) patients had persistent BCRL requiring referral for advanced therapy. Patients with persistent BCRL had significant nodal burden on surgical pathology; eight (89%) had N2/N3 disease. Six (76%) with BCRL refractory to conservative measures died of their breast cancer. CONCLUSION Our results demonstrated that early conservative intervention for breast cancer patients high risk for BCRL who were prospectively monitored by utilizing BIS significantly lowers rates of BCRL. These findings support early prospective screening and intervention for BCRL. Early detection with patient-directed interventions improves patient outcomes and decreases the risk of persistent BCRL.
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Affiliation(s)
- Lyndsey J Kilgore
- Division of Breast Surgery, Department of Surgery, University of Kansas Cancer Center, Kansas City, KS, USA
| | - Sabrina S Korentager
- Division of Breast Surgery, Department of Surgery, University of Kansas Cancer Center, Kansas City, KS, USA
| | - Amanda N Hangge
- Division of Breast Surgery, Department of Surgery, University of Kansas Cancer Center, Kansas City, KS, USA
| | - Amanda L Amin
- Division of Breast Surgery, Department of Surgery, University of Kansas Cancer Center, Kansas City, KS, USA
| | - Christa R Balanoff
- Division of Breast Surgery, Department of Surgery, University of Kansas Cancer Center, Kansas City, KS, USA
| | - Kelsey E Larson
- Division of Breast Surgery, Department of Surgery, University of Kansas Cancer Center, Kansas City, KS, USA
| | - Melissa P Mitchell
- Department of Radiation Oncology, University of Kansas Cancer Center, Kansas City, KS, USA
| | - John G Chen
- Office of Scholarly, Academic and Research Mentoring, University of Kansas Cancer Center, Kansas City, KS, USA
| | - Emily Burgen
- Office of Scholarly, Academic and Research Mentoring, University of Kansas Cancer Center, Kansas City, KS, USA
| | - Qamar J Khan
- Department of Medical Oncology, University of Kansas Cancer Center, Kansas City, KS, USA
| | - Anne P O'Dea
- Department of Medical Oncology, University of Kansas Cancer Center, Kansas City, KS, USA
| | - Lauren Nye
- Department of Medical Oncology, University of Kansas Cancer Center, Kansas City, KS, USA
| | - Priyanka Sharma
- Department of Medical Oncology, University of Kansas Cancer Center, Kansas City, KS, USA
| | - Jamie L Wagner
- Division of Breast Surgery, Department of Surgery, University of Kansas Cancer Center, Kansas City, KS, USA.
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Imai N, Kitayama M, Shibahara A, Bessho Y, Shibusawa M, Noro A, Inakami K, Hanamura N, Imai H, Ogawa T. Strategy for the accurate preoperative evaluation of the number of metastatic axillary lymph nodes in breast cancer. Asian J Surg 2018; 42:228-234. [PMID: 29661546 DOI: 10.1016/j.asjsur.2018.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Revised: 02/14/2018] [Accepted: 03/06/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND After the ACOSOG Z0011 trial, it became important to evaluate the number of metastatic axillary lymph nodes (LNs) preoperatively. The purpose of this paper is to confirm whether the number of metastases can be accurately diagnosed by preoperative computed tomography (CT), ultrasound sonography (US), and US-guided fine-needle aspiration cytology (FNAC). METHODS We retrospectively analyzed the axillary LNs finding of preoperative CT/US of 470 breast cancer patients. Metastasis was suspected based on the following findings: LNs with a long-axis diameter of ≥10 mm or a short-axis diameter of ≥5 mm on CT, and LNs with the absence of a fatty hilum, focal cortical thickness or a cortical thickness ≥2 mm on US. We also examined the results of FNAC making a rapid bedside diagnosis (bedside-FNAC) of 162 LNs that were suspected to metastatic based on the US findings. RESULTS On CT, all cases with ≥3 LNs with a long-axis diameter of ≥10 mm and a short-axis diameter of ≥5 mm had metastasis. However, there was no relationship between the number of detected LNs and the number of metastases. On US, 75.7% of LNs with the absence of a fatty hilum and all LNs with cortical thickness ≥6 mm had metastasis. The accuracy of bedside-FNAC for suspicious LNs was 100%. CONCLUSIONS Although we can pick up LNs that are likely to have metastasis on CT/US, it was impossible to accurately predict the number of metastases on CT/US. However, bedside-FNAC of suspicious LNs could accurately predict the number of metastases.
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Affiliation(s)
- Nao Imai
- Department of Breast Surgery, Mie University Hospital, Mie, Japan.
| | | | - Akiko Shibahara
- Department of Pathologic Oncology, Mie University Graduate School of Medicine, Mie, Japan
| | - Yuri Bessho
- Department of Central Laboratory, Mie University Hospital, Mie, Japan
| | - Mai Shibusawa
- Department of Breast Surgery, Mie University Hospital, Mie, Japan
| | - Aya Noro
- Department of Breast Surgery, Mie University Hospital, Mie, Japan
| | - Keiko Inakami
- Department of Breast Surgery, Mie University Hospital, Mie, Japan
| | - Noriko Hanamura
- Department of Breast Surgery, Mie University Hospital, Mie, Japan; Breast Center, Mie University Hospital, Mie, Japan
| | - Hiroshi Imai
- Department of Pathologic Oncology, Mie University Graduate School of Medicine, Mie, Japan
| | - Tomoko Ogawa
- Department of Breast Surgery, Mie University Hospital, Mie, Japan; Breast Center, Mie University Hospital, Mie, Japan
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de Meric de Bellefon M, Lemanski C, Ducteil A, Fenoglietto P, Azria D, Bourgier C. Management of the Axilla in the Era of Breast Cancer Heterogeneity. Front Oncol 2018; 8:84. [PMID: 29670853 PMCID: PMC5893721 DOI: 10.3389/fonc.2018.00084] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 03/12/2018] [Indexed: 01/07/2023] Open
Abstract
Systemic cancer therapies take into account breast cancer (BC) heterogeneity by targeting pathways specifically involved in some BC subtypes. On the other hand, BC intrinsic radiosensitivity is poorly understood and studied. Hence, radiotherapy personalization in BC is still “work in progress”. In this review, we will summarize the existing data on the management of axillary lymph nodes in BC, the impact of BC radiotherapy on axillary management, the indications for axillary radiotherapy, and biomarkers to predict patients’ outcome (tumor control and late toxicities) after axillary irradiation.
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Affiliation(s)
| | - Claire Lemanski
- Institut Régional du Cancer de Montpellier (ICM), Montpellier, France
| | - Angélique Ducteil
- Institut Régional du Cancer de Montpellier (ICM), Montpellier, France
| | | | - David Azria
- Institut Régional du Cancer de Montpellier (ICM), Montpellier, France.,Institut de Recherche en Cancérologie de Montpellier (IRCM), INSERM U1194, Montpellier, France.,Université de Montpellier, Montpellier, France
| | - Celine Bourgier
- Institut Régional du Cancer de Montpellier (ICM), Montpellier, France.,Institut de Recherche en Cancérologie de Montpellier (IRCM), INSERM U1194, Montpellier, France.,Université de Montpellier, Montpellier, France
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Bakar Y, Tuğral A, Üyetürk Ü. Measurement of Local Tissue Water in Patients with Breast Cancer-Related Lymphedema. Lymphat Res Biol 2018; 16:160-164. [DOI: 10.1089/lrb.2016.0054] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Yeşim Bakar
- Abant Izzet Baysal University, School of Physical Therapy and Rehabilitation, Bolu, Turkey
| | - Alper Tuğral
- Abant Izzet Baysal University, School of Physical Therapy and Rehabilitation, Bolu, Turkey
| | - Ümmügül Üyetürk
- Abant Izzet Baysal University, Faculty of Medicine, Department of Medical Oncology, Bolu, Turkey
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The arrival of axilla conserving therapy (ACT). Is this the second revolution in locoregional management of breast cancer care? Radiother Oncol 2018; 128:591-592. [PMID: 29482843 DOI: 10.1016/j.radonc.2018.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 02/07/2018] [Accepted: 02/09/2018] [Indexed: 11/20/2022]
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The incidence and risk factors of related lymphedema for breast cancer survivors post-operation: a 2-year follow-up prospective cohort study. Breast Cancer 2018; 25:309-314. [DOI: 10.1007/s12282-018-0830-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 01/03/2018] [Indexed: 02/01/2023]
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Güven HE, Doğan L, Kültüroğlu MO, Gülçelik MA, Özaslan C. Factors Influencing Non-sentinel Node Metastasis in Patients with Macrometastatic Sentinel Lymph Node Involvement and Validation of Three Commonly Used Nomograms. Eur J Breast Health 2017; 13:189-193. [PMID: 29082376 DOI: 10.5152/ejbh.2017.3545] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 06/19/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Omitting axillary lymph node dissection (ALND) in a subgroup of patients with sentinel lymph node (SLN) metastasis is becoming a widely accepted practice. Avoiding the well-known complications of ALND is the sole aim without compromising the curative intention of surgery. MATERIALS AND METHODS The data were probed for breast cancer patients that were operated on between February 2014 and June 2016. SLN biopsies were performed in 507 patients and out of 157 patients who underwent ALND for a metastatic SLN, 151 were found eligible for the analyses as having macrometastatic (>2mm) SLN. MD Anderson, Memorial Sloan Kettering Cancer Center and Helsinki nomograms were also tested in our patient population. RESULTS Pathologic tumor size greater than 2 cm, the ratio of metastatic SLN to dissected SLN, metastatic tumor greater than 1 cm and tumors that extended outside the SLN's capsule were found to be associated with non-sentinel node metastasis in both univariate and multivariate tests. MD Anderson nomogram performed well with an area under the curve (AUC) value of 0.72. CONCLUSION Our results suggest that ALND should be considered in patients with macrometastatic SLN greater than 10 mm in size, have extracapsular extension, have metastatic SLNs at a rate of more than 50% and whose primary tumor is greater than 2 cm.
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Affiliation(s)
- Hikmet Erhan Güven
- Department of General Surgery, Ankara Oncology Training and Research Hospital, Ankara, Turkey
| | - Lütfi Doğan
- Department of General Surgery, Ankara Oncology Training and Research Hospital, Ankara, Turkey
| | - Mahmut Onur Kültüroğlu
- Department of General Surgery, Ankara Oncology Training and Research Hospital, Ankara, Turkey
| | - Mehmet Ali Gülçelik
- Department of General Surgery, Ankara Oncology Training and Research Hospital, Ankara, Turkey
| | - Cihangir Özaslan
- Department of General Surgery, Ankara Oncology Training and Research Hospital, Ankara, Turkey
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Whitworth PW, Cooper A. Reducing chronic breast cancer-related lymphedema utilizing a program of prospective surveillance with bioimpedance spectroscopy. Breast J 2017; 24:62-65. [DOI: 10.1111/tbj.12939] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 07/21/2017] [Accepted: 07/27/2017] [Indexed: 12/01/2022]
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31
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Kaufman DI, Shah C, Vicini FA, Rizzi M. Utilization of bioimpedance spectroscopy in the prevention of chronic breast cancer-related lymphedema. Breast Cancer Res Treat 2017; 166:809-815. [PMID: 28831632 PMCID: PMC5680358 DOI: 10.1007/s10549-017-4451-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2017] [Accepted: 08/07/2017] [Indexed: 11/30/2022]
Abstract
Background
This analysis was performed to assess the impact of early intervention following prospective surveillance using bioimpedance spectroscopy (BIS) to detect and manage breast cancer-related lymphedema (BCRL). Methods From 8/2010 to 12/2016, 206 consecutive patients were evaluated with BIS. The protocol included pre-operative assessment with L-Dex as well as post-operative assessments at regular intervals. Patients with L-Dex scores >10 from baseline were considered to have subclinical BCRL and were treated with over-the-counter (OTC) compression sleeve for 4 weeks. High-risk patients were defined as undergoing axillary lymph node dissection (ALND), receiving regional nodal irradiation (RNI), or taxane chemotherapy. Chronic BCRL was defined as the need for complex decongestive physiotherapy (CDP). Results Median follow-up was 25.9 months. Overall, 17% of patients had one high-risk feature, 8% two, and 7% had three. 9.8% of patients were diagnosed with subclinical BCRL with highest rates seen following ALND (23 vs. 7%, p = 0.01). Development of subclinical BCRL was associated with ALND and receipt of RNI. At last follow-up, no patients (0%) developed chronic, clinically detectable, BCRL. Subset analysis was performed of the 30 patients undergoing ALND. Median number of nodes removed was 18 and median number of positive nodes was 2. 77% received taxane chemotherapy, 62% axillary RT, and 48% had elevated BMI. Overall, 86% of patients had at least one additional high-risk feature, 70% at least two, and 23% had all three. Seven patients (23%) had abnormally elevated L-Dex scores at some point during follow-up. To date, none has required CDP. Conclusions The results of this study support prospective surveillance utilizing BIS initiated pre-operatively with subsequent post-operative follow-up measurements for the detection of subclinical BCRL. Intervention triggered by subclinical BCRL detection with an elevated L-Dex score was associated with no cases progressing to chronic, clinically detectable BCRL even in very high-risk patients.
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Affiliation(s)
| | - Chirag Shah
- Department of Radiation Oncology, Cleveland Clinic, Taussig Cancer Institute, Cleveland, OH, USA
| | - Frank A Vicini
- Michigan Healthcare Professionals, 21st Century Oncology, Farmington Hills, MI, USA
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McLaughlin SA, Staley AC, Vicini F, Thiruchelvam P, Hutchison NA, Mendez J, MacNeill F, Rockson SG, DeSnyder SM, Klimberg S, Alatriste M, Boccardo F, Smith ML, Feldman SM. Considerations for Clinicians in the Diagnosis, Prevention, and Treatment of Breast Cancer-Related Lymphedema: Recommendations from a Multidisciplinary Expert ASBrS Panel : Part 1: Definitions, Assessments, Education, and Future Directions. Ann Surg Oncol 2017; 24:2818-2826. [PMID: 28766232 DOI: 10.1245/s10434-017-5982-4] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Indexed: 12/21/2022]
Affiliation(s)
| | | | - Frank Vicini
- Radiation Oncology, UCLA School of Medicine, Los Angeles, USA
| | | | - Nancy A Hutchison
- Courage Kenny Rehabilitation Institute of AllinaHealth, Minneapolis, MN, USA
| | | | - Fiona MacNeill
- Association of Breast Surgery Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - Stanley G Rockson
- Center for Lymphatic and Venous Disorders, Stanford University School of Medicine, Stanford, CA, USA
| | - Sarah M DeSnyder
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | - Francesco Boccardo
- Department of Surgery, Unit of Lymphatic Surgery - S. Martino University Hospital, University of Genoa, Genoa, Italy
| | - Mark L Smith
- Hofstra Northwell School of Medicine, Northwell Health Cancer Institute, Lake Success, NY, USA
| | - Sheldon M Feldman
- Division of Breast Surgery and Breast Surgical Oncology, Department of Surgery, Montefiore Medical Center, The University Hospital for the Albert Einstein College of Medicine, New York, NY, USA
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Nguyen TT, Hoskin TL, Habermann EB, Cheville AL, Boughey JC. Breast Cancer-Related Lymphedema Risk is Related to Multidisciplinary Treatment and Not Surgery Alone: Results from a Large Cohort Study. Ann Surg Oncol 2017; 24:2972-2980. [PMID: 28766228 DOI: 10.1245/s10434-017-5960-x] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Breast cancer-related lymphedema (BCRL) is a significant complication for women undergoing treatment. We assessed BCRL incidence and risk factors in a large population-based cohort. METHODS We utilized the Olmsted County Rochester Epidemiology Project Breast Cancer Cohort from 1990-2010 and ascertained BCRL and risk factors. The cumulative incidence estimator was used to estimate the rate of BCRL; competing risks regression was used for multivariable analysis. RESULTS A total of 1794 patients with stage 0-3 breast cancer with a median of 10 years follow-up were included. The cumulative incidence of BCRL diagnosis within 5 years was 9.1% [95% confidence interval (CI) 7.8-10.5%]. No BCRL events occurred among patients without axillary surgery. In the axillary surgery subset (n = 1512), the 5-year incidence of BCRL was 5.3% in sentinel lymph node (SLN) surgery and 15.9% in axillary dissection (ALND) patients (p < 0.001). In patients treated with surgery only, BCRL rates were not different between ALND versus SLN (3.5 and 4.1% at 5 years, p = 0.36). Addition of breast or chest wall radiation more than doubled the BCRL rate in ALND patients (3.5 vs. 9.5% at 5 years, p = 0.01). The groups with highest risk (>25% at 5 years) all involved ALND with nodal RT and/or anthracycline/cytoxan + taxane chemotherapy. In multivariable analysis of patients with any axillary surgery factors significantly associated with BCRL were ALND, chemotherapy, radiation, and obesity. CONCLUSIONS BCRL is a sequelae of multimodal breast cancer treatment and risk is multifactorial. BCRL rates are higher in patients receiving chemotherapy, radiation, ALND, more advanced disease stage, and higher body mass index.
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Affiliation(s)
- Toan T Nguyen
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Tanya L Hoskin
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA.,The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth B Habermann
- Department of Surgery, Mayo Clinic, Rochester, MN, USA.,The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Andrea L Cheville
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
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Bromham N, Schmidt‐Hansen M, Astin M, Hasler E, Reed MW. Axillary treatment for operable primary breast cancer. Cochrane Database Syst Rev 2017; 1:CD004561. [PMID: 28052186 PMCID: PMC6464919 DOI: 10.1002/14651858.cd004561.pub3] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Axillary surgery is an established part of the management of primary breast cancer. It provides staging information to guide adjuvant therapy and potentially local control of axillary disease. Several alternative approaches to axillary surgery are available, most of which aim to spare a proportion of women the morbidity of complete axillary dissection. OBJECTIVES To assess the benefits and harms of alternative approaches to axillary surgery (including omitting such surgery altogether) in terms of overall survival; local, regional and distant recurrences; and adverse events. SEARCH METHODS We searched the Cochrane Breast Cancer Group Specialised Register, MEDLINE, Pre-MEDLINE, Embase, CENTRAL, the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov on 12 March 2015 without language restrictions. We also contacted study authors and checked reference lists. SELECTION CRITERIA Randomised controlled trials (RCTs) including women with clinically defined operable primary breast cancer conducted to compare axillary lymph node dissection (ALND) with no axillary surgery, axillary sampling or sentinel lymph node biopsy (SLNB); RCTs comparing axillary sampling with SLNB or no axillary surgery; RCTs comparing SLNB with no axillary surgery; and RCTs comparing ALND with or without radiotherapy (RT) versus RT alone. DATA COLLECTION AND ANALYSIS Two review authors independently assessed each potentially relevant trial for inclusion. We independently extracted outcome data, risk of bias information and study characteristics from all included trials. We pooled data according to trial interventions, and we used hazard ratios (HRs) for time-to-event outcomes and odds ratios (OR) for binary outcomes. MAIN RESULTS We included 26 RCTs in this review. Studies were at low or unclear risk of selection bias. Blinding was not done, but this was only considered a source of bias for outcomes with potential for subjectivity in measurements. We found no RCTs of axillary sampling versus SLNB, axillary sampling versus no axillary surgery or SLNB versus no axillary surgery. No axillary surgery versus ALND Ten trials involving 3849 participants compared no axillary surgery versus ALND. Moderate quality evidence showed no important differences between overall survival of women in the two groups (HR 1.06, 95% confidence interval (CI) 0.96 to 1.17; 3849 participants; 10 studies) although no axillary surgery increased the risk of locoregional recurrence (HR ranging from 1.10 to 3.06; 20,863 person-years of follow-up; four studies). It was uncertain whether no surgery increased the risk of distant metastasis compared with ALND (HR 1.06, 95% CI 0.87 to 1.30; 946 participants; two studies). Low-quality evidence indicated no axillary surgery decreased the risk of lymphoedema compared with ALND (OR 0.31, 95% CI 0.23 to 0.43; 1714 participants; four studies). Axillary sampling versus ALND Six trials involving 1559 participants compared axillary sampling versus ALND. Low-quality evidence indicated similar effectiveness of axillary sampling compared with ALND in terms of overall survival (HR 0.94, 95% CI 0.73 to 1.21; 967 participants; three studies) but it was unclear whether axillary sampling led to increased risk of local recurrence compared with ALND (HR 1.41, 95% CI 0.94 to 2.12; 1404 participants; three studies). The relative effectiveness of axillary sampling and ALND for locoregional recurrence (HR 0.74, 95% CI 0.46 to 1.20; 406 participants; one study) and distant metastasis was uncertain (HR 1.05, 95% CI 0.74 to 1.49; 406 participants; one study). Lymphoedema was less likely after axillary sampling than after ALND (OR 0.32, 95% CI 0.13 to 0.81; 80 participants; one study). SLNB versus ALND Seven trials involving 9426 participants compared SLNB with ALND. Moderate-quality evidence showed similar overall survival following SLNB compared with ALND (HR 1.05, 95% CI 0.89 to 1.25; 6352 participants; three studies; moderate-quality evidence). Differences in local recurrence (HR 0.94, 95% CI 0.24 to 3.77; 516 participants; one study), locoregional recurrence (HR 0.96, 95% CI 0.74 to 1.24; 5611 participants; one study) and distant metastasis (HR 0.80, 95% CI 0.42 to 1.53; 516 participants; one study) were uncertain. However, studies showed little absolute difference in the aforementioned outcomes. Lymphoedema was less likely after SLNB than ALND (OR ranged from 0.04 to 0.60; three studies; 1965 participants; low-quality evidence). Three studies including 1755 participants reported quality of life: Investigators in two studies found quality of life better after SLNB than ALND, and in the other study observed no difference. RT versus ALND Four trials involving 2585 participants compared RT alone with ALND (with or without RT). High-quality evidence indicated that overall survival was reduced among women treated with radiotherapy alone compared with those treated with ALND (HR 1.10, 95% CI 1.00 to 1.21; 2469 participants; four studies), and local recurrence was less likely in women treated with radiotherapy than in those treated with ALND (HR 0.80, 95% CI 0.64 to 0.99; 22,256 person-years of follow-up; four studies). Risk of distant metastasis was similar for radiotherapy alone as for ALND (HR 1.07, 95% CI 0.93 to 1.25; 1313 participants; one study), and whether lymphoedema was less likely after RT alone than ALND remained uncertain (OR 0.47, 95% CI 0.16 to 1.44; 200 participants; one study). Less surgery versus ALND When combining results from all trials, treatment involving less surgery was associated with reduced overall survival compared with ALND (HR 1.08, 95% CI 1.01 to 1.17; 6478 participants; 18 studies). Whether local recurrence was reduced with less axillary surgery when compared with ALND was uncertain (HR 0.90, 95% CI 0.75 to 1.09; 24,176 participant-years of follow up; eight studies). Locoregional recurrence was more likely with less surgery than with ALND (HR 1.53, 95% CI 1.31 to 1.78; 26,880 participant-years of follow-up; seven studies). Whether risk of distant metastasis was increased after less axillary surgery compared with ALND was uncertain (HR 1.07, 95% CI 0.95 to 1.20; 2665 participants; five studies). Lymphoedema was less likely after less axillary surgery than with ALND (OR 0.37, 95% CI 0.29 to 0.46; 3964 participants; nine studies).No studies reported on disease control in the axilla. AUTHORS' CONCLUSIONS This review confirms the benefit of SLNB and axillary sampling as alternatives to ALND for axillary staging, supporting the view that ALND of the clinically and radiologically uninvolved axilla is no longer acceptable practice in people with breast cancer.
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Affiliation(s)
- Nathan Bromham
- Royal College of Obstetricians and GynaecologistsNational Guideline Alliance27 Sussex PlaceRegents ParkLondonEnglandUKNW1 4RG
| | - Mia Schmidt‐Hansen
- Royal College of Obstetricians and GynaecologistsNational Guideline Alliance27 Sussex PlaceRegents ParkLondonEnglandUKNW1 4RG
| | - Margaret Astin
- School of Social and Community Medicine, University of BristolCentre for Academic Primary CareCanynge Hall39 Whatley RoadBristolUKBS8 2PS
| | - Elise Hasler
- Royal College of Obstetricians and GynaecologistsNational Guideline Alliance27 Sussex PlaceRegents ParkLondonEnglandUKNW1 4RG
| | - Malcolm W Reed
- Universities of Brighton and SussexBrighton and Sussex Medical SchoolBSMS Teaching BuildingUinversity of Sussex, FalmerBrightonEast SussexUKBN1 9PX
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Chang JS, Byun HK, Kim JW, Kim KH, Lee J, Cho Y, Lee IJ, Keum KC, Suh CO, Kim YB. Three-dimensional analysis of patterns of locoregional recurrence after treatment in breast cancer patients: Validation of the ESTRO consensus guideline on target volume. Radiother Oncol 2017; 122:24-29. [DOI: 10.1016/j.radonc.2016.10.016] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 10/04/2016] [Accepted: 10/17/2016] [Indexed: 10/20/2022]
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Shaitelman SF, Chiang YJ, Griffin KD, DeSnyder SM, Smith BD, Schaverien MV, Woodward WA, Cormier JN. Radiation therapy targets and the risk of breast cancer-related lymphedema: a systematic review and network meta-analysis. Breast Cancer Res Treat 2016; 162:201-215. [PMID: 28012086 DOI: 10.1007/s10549-016-4089-0] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 12/16/2016] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Simona F Shaitelman
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1202, Houston, TX, 77030, USA.
| | - Yi-Ju Chiang
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1484, Houston, TX, 77030, USA
| | - Kate D Griffin
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1484, Houston, TX, 77030, USA
| | - Sarah M DeSnyder
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1434, Houston, TX, 77030, USA
| | - Benjamin D Smith
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1202, Houston, TX, 77030, USA
| | - Mark V Schaverien
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1488, Houston, TX, 77030, USA
| | - Wendy A Woodward
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1202, Houston, TX, 77030, USA
| | - Janice N Cormier
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1484, Houston, TX, 77030, USA
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Yoo JS, Chung SH, Lim MC, Kim YJ, Kim KG, Hwang JH, Kim YH. Computed tomography-based quantitative assessment of lower extremity lymphedema following treatment for gynecologic cancer. J Gynecol Oncol 2016; 28:e18. [PMID: 28028991 PMCID: PMC5323285 DOI: 10.3802/jgo.2017.28.e18] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 11/03/2016] [Accepted: 11/16/2016] [Indexed: 11/30/2022] Open
Abstract
Objective To develop an algorithmic quantitative skin and subcutaneous tissue volume measurement protocol for lower extremity lymphedema (LEL) patients using computed tomography (CT), to verify the usefulness of the measurement techniques in LEL patients, and to observe the structural characteristics of subcutaneous tissue according to the progression of LEL in gynecologic cancer. Methods A program for algorithmic quantitative analysis of lower extremity CT scans has been developed to measure the skin and subcutaneous volume, muscle compartment volume, and the extent of the peculiar trabecular area with a honeycombed pattern. The CT venographies of 50 lower extremities from 25 subjects were reviewed in two groups (acute and chronic lymphedema). Results A significant increase in the total volume, subcutaneous volume, and extent of peculiar trabecular area with a honeycombed pattern except quantitative muscle volume was identified in the more-affected limb. The correlation of CT-based total volume and subcutaneous volume measurements with volumetry measurement was strong (correlation coefficient: 0.747 and 0.749, respectively). The larger extent of peculiar trabecular area with a honeycombed pattern in the subcutaneous tissue was identified in the more-affected limb of chronic lymphedema group. Conclusion CT-based quantitative assessments could provide objective volume measurements and information about the structural characteristics of subcutaneous tissue in women with LEL following treatment for gynecologic cancer.
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Affiliation(s)
- Ji Sung Yoo
- Rehabilitation Medicine, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Seung Hyun Chung
- Rehabilitation Medicine, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Myong Cheol Lim
- Gynecologic Cancer Branch, Center for Uterine Cancer, and Center for Clinical Trials, Research Institute and Hospitaland Cancer Control and Policy, Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, Korea
| | - Young Jae Kim
- Biomedical Engineering Branch, Division of Precision Medicine and Cancer Informatics, Research Institute, National Cancer Center, Goyang, Korea
| | - Kwang Gi Kim
- Biomedical Engineering Branch, Division of Precision Medicine and Cancer Informatics, Research Institute, National Cancer Center, Goyang, Korea
| | - Ji Hye Hwang
- Department of Physical and Rehabilitation Medicine, Center for Supportive Care, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yun Hee Kim
- Department of Physical and Rehabilitation Medicine, Center for Prevention and Rehabilitation, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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Early Detection of Lymphatic Disorder and Treatment for Lymphedema following Breast Cancer. Plast Reconstr Surg 2016; 138:192e-202e. [DOI: 10.1097/prs.0000000000002337] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Zhang J, Wang C. Axillary radiotherapy: an alternative treatment option for adjuvant axillary management of breast cancer. Sci Rep 2016; 6:26304. [PMID: 27212421 PMCID: PMC4876332 DOI: 10.1038/srep26304] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 04/29/2016] [Indexed: 01/13/2023] Open
Abstract
Axillary lymph node dissection is standard management of axilla in invasive breast cancer. Radiotherapy also is important in local treatment. It is controversial as to whether axillary radiotherapy can displace axillary lymph node dissection. We performed a meta-analysis comparing axillary radiotherapy with axillary dissection. No significant difference was observed for disease free survival and overall survival between the radiation group and the dissection group. There was also no significant difference in either the axillary recurrence or the local recurrence between the two groups. But the axillary relapse rate in the radiation group was higher than in the surgery group at five-year follow-up while the local recurrence rate in the surgery group was higher than in the radiation group. A subgroup analysis showed that the difference in the axillary recurrence rate (RR = 0.20, P = 0.01) and local recurrence rate (RR = 4.7, P = 0.01) mainly appeared in the clinical node-positive subgroup. The edema rate in the surgery group was higher than in the radiation group (RR = 2.08, 95%: 1.71–2.54, P < 0.0001). We concluded that radiotherapy may be an alternative treatment option for adjuvant management of the axilla in selected sub-groups of patients.
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Affiliation(s)
- Jie Zhang
- Department of Breast Surgery, Affiliated Union Hospital of Fujian Medical University, Fuzhou, China
| | - Chuan Wang
- Department of Breast Surgery, Affiliated Union Hospital of Fujian Medical University, Fuzhou, China
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Breast cancer-related lymphoedema and venepuncture: a review and evidence-based recommendations. Breast Cancer Res Treat 2015; 154:455-61. [DOI: 10.1007/s10549-015-3639-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 11/13/2015] [Indexed: 10/22/2022]
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Abstract
Lymphedema is one of the main late effects from breast cancer treatment affecting 3-60% of breast cancer survivors. Primarily occurring in the hand, arm, and/or affected breast, symptoms of lymphedema include swelling, pain, redness, restriction of arm/hand movement, tightness and feelings of fullness. These symptoms not only may limit physical functioning but also negatively affect quality of life, body image, social functioning, and financial status of breast cancer survivors with lymphedema. Unfortunately, there are no standardized methods for prevention, diagnosis, and treatment of breast cancer-related lymphedema. Despite its prevalence and lack of clinical guidelines, lymphedema is one of the most poorly understood, relatively underestimated, and least researched complications of cancer treatment. This chapter reviews the current problem of breast cancer-related lymphedema by investigating prevention and risk reduction strategies, diagnosis, and treatment. In addition, this chapter identifies future research opportunities focusing on prevention and risk reduction strategies, quality of life and physical function, surveillance, patient education, cost, diagnosis, and treatment. Challenges and recommendations for future research in these areas, particularly among underserved populations, are discussed.
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Breast Cancer Rehabilitation. TOPICS IN GERIATRIC REHABILITATION 2015. [DOI: 10.1097/tgr.0000000000000082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Voutsadakis IA, Spadafora S. Axillary lymph node management in breast cancer with positive sentinel lymph node biopsy. World J Clin Oncol 2015; 6:1-6. [PMID: 25667909 PMCID: PMC4318745 DOI: 10.5306/wjco.v6.i1.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Revised: 11/08/2014] [Accepted: 12/10/2014] [Indexed: 02/06/2023] Open
Abstract
The surgical treatment of localized breast cancer has become progressively less aggressive over the years. The management of the axillary lymph nodes has been modified by the introduction of sentinel lymph node biopsy. Axillary dissection can be avoided in patients with sentinel lymph node negative biopsies. Based on randomized trials data, it has been proposed that no lymph node dissection should be carried out even in certain patients with sentinel lymph node positive biopsies. This commentary discusses the basis of such recommendations and cautions against a general omission of lymph node dissection in breast cancer patients with positive sentinel lymph node biopsies. Instead, an individualized approach based on axillary tumor burden and biology of the cancer should be considered.
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Leung N, Furniss D, Giele H. Modern surgical management of breast cancer therapy related upper limb and breast lymphoedema. Maturitas 2015; 80:384-90. [PMID: 25747119 DOI: 10.1016/j.maturitas.2015.01.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 01/24/2015] [Indexed: 11/27/2022]
Abstract
Breast cancer is the commonest cancer in the UK. Advances in breast cancer treatment means that the sequelae of treatment are affecting more women and for a longer duration. Lymphoedema is one such sequela, with wide-ranging implications, from serious functional and psychological effects at the individual level to wider economic burdens to society. Breast cancer-related lymphoedema is principally managed by conservative therapy comprising compression garments and manual decongestive massage. This approach is effective for early stages of lymphoedema, but it is not curative and the effectiveness depends on patient compliance. Early surgical approaches were ablative, gave significant morbidity and hence, reserved for the most severe cases of refractory lymphoedema. However, recent non-ablative reconstructive surgical approaches have seen a revival of interest in the prevention or surgical management of breast cancer-related lymphoedema. This review examines the modern surgical techniques for the treatment of breast cancer-related lymphoedema. Liposuction reduces the volume and symptoms of lymphedema, but requires continual compressive therapy to avoid recurrence. Lymphatic reconstruction or bypass techniques including lymph node transfer (inguinal nodes are transferred to the affected limb), lymphatico-lymphatic bypass (lymphatics bypass the axilla using a lymph vessel graft reconstructing lymphatic flow from arm to neck) and lymphaticovenous anastomoses (lymphatics in the arm are joined to the venous system aiding lymph drainage) show promise in reducing lymphedema significantly. Further research is required, including into the role of primary lymphaticovenous anastomoses in the prevention of lymphedema at the time of axillary dissection.
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Affiliation(s)
- Nelson Leung
- Foundation Programme, Oxford Deanery, Oxford Radcliffe Hospitals NHS Trust, Oxford OX3 9DU, UK
| | - Dominic Furniss
- Department of Plastic and Reconstructive Surgery, Oxford Radcliffe Hospitals NHS Trust, Oxford OX3 9DU, UK
| | - Henk Giele
- Department of Plastic and Reconstructive Surgery, Oxford Radcliffe Hospitals NHS Trust, Oxford OX3 9DU, UK.
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Johnson KC, Kennedy AG, Henry SM. Clinical Measurements of Lymphedema. Lymphat Res Biol 2014; 12:216-21. [DOI: 10.1089/lrb.2014.0019] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kristine C. Johnson
- Department of Rehabilitation and Movement Science, University of Vermont, Burlington, Vermont
| | - Amanda G. Kennedy
- Department of Clinical and Translational Science, University of Vermont, Burlington, Vermont
| | - Sharon M. Henry
- Department of Rehabilitation and Movement Science, University of Vermont, Burlington, Vermont
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Donker M, van Tienhoven G, Straver ME, Meijnen P, van de Velde CJH, Mansel RE, Cataliotti L, Westenberg AH, Klinkenbijl JHG, Orzalesi L, Bouma WH, van der Mijle HCJ, Nieuwenhuijzen GAP, Veltkamp SC, Slaets L, Duez NJ, de Graaf PW, van Dalen T, Marinelli A, Rijna H, Snoj M, Bundred NJ, Merkus JWS, Belkacemi Y, Petignat P, Schinagl DAX, Coens C, Messina CGM, Bogaerts J, Rutgers EJT. Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer (EORTC 10981-22023 AMAROS): a randomised, multicentre, open-label, phase 3 non-inferiority trial. Lancet Oncol 2014; 15:1303-10. [PMID: 25439688 PMCID: PMC4291166 DOI: 10.1016/s1470-2045(14)70460-7] [Citation(s) in RCA: 1129] [Impact Index Per Article: 112.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND If treatment of the axilla is indicated in patients with breast cancer who have a positive sentinel node, axillary lymph node dissection is the present standard. Although axillary lymph node dissection provides excellent regional control, it is associated with harmful side-effects. We aimed to assess whether axillary radiotherapy provides comparable regional control with fewer side-effects. METHODS Patients with T1-2 primary breast cancer and no palpable lymphadenopathy were enrolled in the randomised, multicentre, open-label, phase 3 non-inferiority EORTC 10981-22023 AMAROS trial. Patients were randomly assigned (1:1) by a computer-generated allocation schedule to receive either axillary lymph node dissection or axillary radiotherapy in case of a positive sentinel node, stratified by institution. The primary endpoint was non-inferiority of 5-year axillary recurrence, considered to be not more than 4% for the axillary radiotherapy group compared with an expected 2% in the axillary lymph node dissection group. Analyses were by intention to treat and per protocol. The AMAROS trial is registered with ClinicalTrials.gov, number NCT00014612. FINDINGS Between Feb 19, 2001, and April 29, 2010, 4823 patients were enrolled at 34 centres from nine European countries, of whom 4806 were eligible for randomisation. 2402 patients were randomly assigned to receive axillary lymph node dissection and 2404 to receive axillary radiotherapy. Of the 1425 patients with a positive sentinel node, 744 had been randomly assigned to axillary lymph node dissection and 681 to axillary radiotherapy; these patients constituted the intention-to-treat population. Median follow-up was 6·1 years (IQR 4·1-8·0) for the patients with positive sentinel lymph nodes. In the axillary lymph node dissection group, 220 (33%) of 672 patients who underwent axillary lymph node dissection had additional positive nodes. Axillary recurrence occurred in four of 744 patients in the axillary lymph node dissection group and seven of 681 in the axillary radiotherapy group. 5-year axillary recurrence was 0·43% (95% CI 0·00-0·92) after axillary lymph node dissection versus 1·19% (0·31-2·08) after axillary radiotherapy. The planned non-inferiority test was underpowered because of the low number of events. The one-sided 95% CI for the underpowered non-inferiority test on the hazard ratio was 0·00-5·27, with a non-inferiority margin of 2. Lymphoedema in the ipsilateral arm was noted significantly more often after axillary lymph node dissection than after axillary radiotherapy at 1 year, 3 years, and 5 years. INTERPRETATION Axillary lymph node dissection and axillary radiotherapy after a positive sentinel node provide excellent and comparable axillary control for patients with T1-2 primary breast cancer and no palpable lymphadenopathy. Axillary radiotherapy results in significantly less morbidity. FUNDING EORTC Charitable Trust.
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Affiliation(s)
- Mila Donker
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | - Marieke E Straver
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Philip Meijnen
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | | | | | | | | | | | - Willem H Bouma
- Department of Surgery, Gelre Hospital, Apeldoorn, Netherlands
| | | | | | - Sanne C Veltkamp
- Department of Surgery, Amstelland Hospital, Amstelveen, Netherlands
| | - Leen Slaets
- European Organisation for Research and Treatment of Cancer, Brussels, Belgium
| | - Nicole J Duez
- European Organisation for Research and Treatment of Cancer, Brussels, Belgium
| | - Peter W de Graaf
- Department of Surgery, Reinier de Graaf Hospital, Delft, Netherlands
| | - Thijs van Dalen
- Department of Radiation Oncology, University Medical Center, Utrecht, Netherlands
| | - Andreas Marinelli
- Department of Surgery, Medical Center Haaglanden, Westeinde, Den Haag, Netherlands
| | - Herman Rijna
- Department of Surgery, Kennemer Gasthuis, Haarlem, Netherlands
| | - Marko Snoj
- Department of Surgery, Institute of Oncology, Ljubljana, Slovenia
| | - Nigel J Bundred
- Department of Surgery, Manchester University Hospital, Manchester, UK
| | - Jos W S Merkus
- Department of Surgery, Haga Hospital, Den Haag, Netherlands
| | - Yazid Belkacemi
- Department of Radiation Oncology, Centre Oscar Lambret, Lille, France
| | - Patrick Petignat
- Division of Gynecology, University Hospitals of Geneva, Geneva, Switzerland
| | - Dominic A X Schinagl
- Department of Radiation Oncology, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | - Corneel Coens
- European Organisation for Research and Treatment of Cancer, Brussels, Belgium
| | - Carlo G M Messina
- European Organisation for Research and Treatment of Cancer, Brussels, Belgium
| | - Jan Bogaerts
- European Organisation for Research and Treatment of Cancer, Brussels, Belgium
| | - Emiel J T Rutgers
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands.
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Ochoa D, Korourian S, Boneti C, Adkins L, Badgwell B, Klimberg VS. Axillary reverse mapping: five-year experience. Surgery 2014; 156:1261-8. [PMID: 25444319 PMCID: PMC4354953 DOI: 10.1016/j.surg.2014.05.011] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Accepted: 05/12/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND We hypothesize that mapping the lymphatic drainage of the arm with blue dye (axillary reverse mapping, ARM) during axillary lymphadenectomy decreases the likelihood of disruption of lymphatics and subsequent lymphedema. METHODS This institutional review board-approved study from May 2006 to October 2011 involved 360 patients undergoing SLNB and/or ALND. Technetium sulfur colloid (4 mL) was injected subareolarly and 5 mL of blue dye was injected subcutaneously in the volar surface ipsilateral upper extremity (ARM). Data were collected on variations in lymphatic drainage, successful identification and protection of arm lymphatics, crossover, and occurrence of lymphedema. RESULTS A group of 360 patients underwent SLNB and/or ALND. A total of 348 patients underwent a SLNB. Of those, 237/348(68.1%) had a SLNB only and 111/348(31.9%) went on to an ALND due to a positive axilla. An additional 12/360(3.3%) axilla had ALND due to a clinically positive axilla/preoperative core needle biopsy. In 96%(334/348) of patients with SLNB, breast SLNs were hot but not blue; crossover (SLN hot and blue) was seen in 14/348(4%). Blue lymphatics were identified in 80/237(33.7%) of SLN incisions and in 93/123(75.4%) ALND. Average follow-up was 12 months (range 3 to 48 months) and resulted in a SLNB lymphedema rate of 1.7%(4/237) and ALND of 2.4%(3/123). CONCLUSIONS ARM identified significant lymphatic variations draining the upper extremities and facilitated preservation. Metastases in ARM-identified lymph nodes were acceptably low indicating that ARM is safe. ARM added to present-day ALND and SLNB may be useful to lower lymphedema rates.
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Affiliation(s)
- Daniela Ochoa
- Department of Surgery, University of Arkansas for Medical Sciences and the Winthrop P. Rockefeller Institute, Little Rock, AR
| | - Soheila Korourian
- Department of Pathology, University of Arkansas for Medical Sciences and the Winthrop P. Rockefeller Institute, Little Rock, AR
| | - Cristiano Boneti
- Department of Surgery, University of Arkansas for Medical Sciences and the Winthrop P. Rockefeller Institute, Little Rock, AR
| | - Laura Adkins
- Department of Surgery, University of Arkansas for Medical Sciences and the Winthrop P. Rockefeller Institute, Little Rock, AR
| | - Brian Badgwell
- Department of Surgical Oncology, MD Anderson Cancer Center
| | - V Suzanne Klimberg
- Department of Surgery, University of Arkansas for Medical Sciences and the Winthrop P. Rockefeller Institute, Little Rock, AR; Department of Pathology, University of Arkansas for Medical Sciences and the Winthrop P. Rockefeller Institute, Little Rock, AR.
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Boccardo F, Casabona F, DeCian F, Friedman D, Murelli F, Puglisi M, C. Campisi C, Molinari L, Spinaci S, Dessalvi S, Campisi C. Lymphatic Microsurgical Preventing Healing Approach (LYMPHA) for primary surgical prevention of breast cancer-related lymphedema: Over 4 years follow-up. Microsurgery 2014; 34:421-4. [DOI: 10.1002/micr.22254] [Citation(s) in RCA: 136] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Revised: 03/13/2014] [Accepted: 03/14/2014] [Indexed: 11/11/2022]
Affiliation(s)
- Francesco Boccardo
- Department of Surgery-Unit of Lymphatic Surgery; IRCCS S. Martino University Hospital-IST, National Institute for Cancer Research, University of Genoa; Largo R. Benzi 10 16132 Genoa Italy
| | - Federico Casabona
- Department of Surgery-Unit of Gynecology; IRCCS S. Martino University Hospital-IST, National Institute for Cancer Research, University of Genoa; Largo R. Benzi 10 16132 Genoa Italy
| | - Franco DeCian
- Department of Surgery-Unit of Surgical Oncology; IRCCS S. Martino University Hospital-IST, National Institute for Cancer Research, University of Genoa; Largo R. Benzi 10 16132 Genoa Italy
| | - Daniele Friedman
- Department of Surgery-Breast Unit; IRCCS S. Martino University Hospital-IST, National Institute for Cancer Research, University of Genoa; Largo R. Benzi 10 16132 Genoa Italy
| | - Federica Murelli
- Department of Surgery-Breast Unit; IRCCS S. Martino University Hospital-IST, National Institute for Cancer Research, University of Genoa; Largo R. Benzi 10 16132 Genoa Italy
| | - Maria Puglisi
- Department of Surgery-Breast Unit; IRCCS S. Martino University Hospital-IST, National Institute for Cancer Research, University of Genoa; Largo R. Benzi 10 16132 Genoa Italy
| | - Corrado C. Campisi
- Department of Plastic and Reconstructive Surgery; IRCCS S. Martino University Hospital-IST, National Institute for Cancer Research, University of Genoa; Largo R. Benzi 10 16132 Genoa Italy
| | - Lidia Molinari
- Department of Surgery-Unit of Lymphatic Surgery; IRCCS S. Martino University Hospital-IST, National Institute for Cancer Research, University of Genoa; Largo R. Benzi 10 16132 Genoa Italy
| | - Stefano Spinaci
- Department of Surgery-Unit of Lymphatic Surgery; IRCCS S. Martino University Hospital-IST, National Institute for Cancer Research, University of Genoa; Largo R. Benzi 10 16132 Genoa Italy
| | - Sara Dessalvi
- Department of Surgery-Unit of Lymphatic Surgery; IRCCS S. Martino University Hospital-IST, National Institute for Cancer Research, University of Genoa; Largo R. Benzi 10 16132 Genoa Italy
| | - Corradino Campisi
- Department of Surgery-Unit of Lymphatic Surgery; IRCCS S. Martino University Hospital-IST, National Institute for Cancer Research, University of Genoa; Largo R. Benzi 10 16132 Genoa Italy
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BREAST CANCER EDGE TASK FORCE OUTCOMES: Assessment Measures of Secondary Lymphedema in Breast Cancer Survivors. REHABILITATION ONCOLOGY 2014. [DOI: 10.1097/01893697-201432010-00005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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50
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BREAST CANCER EDGE TASK FORCE OUTCOMES: Quality of Life and Functional Outcome Measures for Secondary Lymphedema in Breast Cancer Survivors. REHABILITATION ONCOLOGY 2014. [DOI: 10.1097/01893697-201432010-00003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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