1
|
Brown S, Tadros AB, Montagna G, Bell T, Crowley F, Gallagher EJ, Dayan JH. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) may reduce the risk of developing cancer-related lymphedema following axillary lymph node dissection (ALND). Front Pharmacol 2024; 15:1457363. [PMID: 39318780 PMCID: PMC11420520 DOI: 10.3389/fphar.2024.1457363] [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: 06/30/2024] [Accepted: 08/22/2024] [Indexed: 09/26/2024] Open
Abstract
Purpose Patients undergoing axillary lymph node dissection (ALND) for breast cancer face a high risk of lymphedema, further increased by high body mass index (BMI) and insulin resistance. GLP-1 receptor agonists (GLP-1RAs) have the potential to reduce these risk factors, but their role in lymphedema has never been investigated. The purpose of this study was to determine if GLP-RAs can reduce the risk of lymphedema in patients undergoing ALND. Methods All patients who underwent ALND at a tertiary cancer center between 2010 and 2023 were reviewed. Patients with less than 2 years of follow-up from the time of ALND were excluded. Race, BMI, radiation, chemotherapy history, pre-existing diagnosis of diabetes, lymphedema development after ALND, and the use of GLP-1RAs were analyzed. Multivariate logistic regression analysis was performed to assess if there was a significant reduction in the risk of developing lymphedema after ALND. A sub-group analysis of non-diabetic patients was also performed. Results 3,830 patients who underwent ALND were included, 76 of which were treated with. GLP-1 RAs. The incidence of lymphedema in the GLP-1 RA cohort was 6.6% (5 patients). Compared to 28.5% (1,071 patients) in the non-GLP-1 RA cohort. On multivariate regression analysis, patients who were treated with GLP-1 RA were 86% less likely to develop lymphedema compared to the non-GLP-1 RA cohort (OR 0.14, 95% CI 0.04-0.32, p < 0.0001). A BMI of 25 kg/m 2 or greater was a statistically significant risk factor for developing lymphedema with an odds ratio of 1.34 (95% CI 1.16-1.56, p < 0.0001). Diabetes was associated with lymphedema development that closely approached statistical significance (OR 1.32, 95% CI 0.97-1.78, p = 0.06). A subgroup analysis solely on non-diabetic patients showed similar results. The odds of developing lymphedema were 84% lower for patients without diabetes treated with GLP1-RAs compared to those who did not receive GLP-1 RAs (OR 0.16, 95% CI 0.05-0.40, p < 0.0001). Conclusion GLP1-RAs appear to significantly reduce the risk of lymphedema in patientsundergoing ALND. The mechanism of action may be multifactorial and not limited to weight reduction and insulin resistance. Future prospective analysis is warranted to clarify the role of GLP-1RAs in reducing lymphedema risk.
Collapse
Affiliation(s)
- Stav Brown
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Audree B Tadros
- Department of Surgery, Breast Service, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Giacomo Montagna
- Department of Surgery, Breast Service, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Tajah Bell
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Fionnuala Crowley
- Division of Hematology and Medical Oncology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Emily J Gallagher
- Department of Medicine, Division of Endocrinology, Diabetes and Bone Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Joseph H Dayan
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, United States
- The Institute for Advanced Reconstruction, Plastic and Reconstructive Surgery, Red Bank, Paramus, NJ, United States
| |
Collapse
|
2
|
Jeong HH, Yoon IA, Al-Shomer FM, Suh HP, Pak CJ, Neligan P, Hong JP. Decompression of Axillary Vein: An Essential Adjunct for Advanced Lymphedema. Plast Reconstr Surg 2024; 154:218-226. [PMID: 37647513 DOI: 10.1097/prs.0000000000011032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
BACKGROUND In advanced lymphedema, lymphovenous anastomosis (LVA) can be a solution based on using the pressure gradient between the high-pressure lymphatics and the low-pressure veins. If the vein pressure is high, the effect of surgery will be less optimal. This study evaluated the effect of axillary vein perivascular scar release on LVA. METHODS This is a retrospective study of 40 upper limb stage 2 and 3 lymphedema patients divided into 2 groups with an average follow-up of 33 months (minimum of at least 12 months): the scar release group ( n = 25) and the control group ( n = 15). All patients underwent LVA with or without lymph node transfer. Demographic data, outcome (volumetric change and bioimpedence analysis [BIA]), and major vein (axillary, basilic, and cephalic) diameter changes were evaluated. RESULTS Both groups showed significant reduction in volume and BIA parameters after LVA. The scar release group (24 of 25 with lymph node transfer and 1 without) showed statistically higher reduction of BIA analysis compared with the control group at 1, 6, and 12 months after LVA. The changes in the major veins after axilla scar release showed significant changes in all 3 veins. There was a significant correlation between cephalic vein diameter reduction and BIA measurement. CONCLUSIONS The release of perivascular scar in the axillary vein may result in better outcome after LVA. This is based on the finding that scar release shows correlation between cephalic vein diameter reduction and BIA measurement suggesting reduction of venous pressure in the peripheral vein increasing the pressure gradient between the lymphatic and venous system allowing better outflow after LVA. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
Collapse
Affiliation(s)
- Hyung Hwa Jeong
- From the Department of Plastic Surgery, Asan Medical Center University of Ulsan
| | - In Ah Yoon
- From the Department of Plastic Surgery, Asan Medical Center University of Ulsan
| | - Feras M Al-Shomer
- From the Department of Plastic Surgery, Asan Medical Center University of Ulsan
| | - HyunSuk Peter Suh
- From the Department of Plastic Surgery, Asan Medical Center University of Ulsan
| | - ChangSik John Pak
- From the Department of Plastic Surgery, Asan Medical Center University of Ulsan
| | - Peter Neligan
- Division of Plastic and Reconstructive Surgery, University of Washington
| | - Joon Pio Hong
- From the Department of Plastic Surgery, Asan Medical Center University of Ulsan
| |
Collapse
|
3
|
Noguchi M, Inokuchi M, Yokoi-Noguchi M, Morioka E, Haba Y. Conservative Axillary Surgery May Prevent Arm Lymphedema without Increasing Axillary Recurrence in the Surgical Management of Breast Cancer. Cancers (Basel) 2023; 15:5353. [PMID: 38001613 PMCID: PMC10670757 DOI: 10.3390/cancers15225353] [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: 09/28/2023] [Revised: 11/06/2023] [Accepted: 11/06/2023] [Indexed: 11/26/2023] Open
Abstract
Axillary lymph node dissection (ALND) has been associated with postoperative morbidities, including arm lymphedema, shoulder dysfunction, and paresthesia. Sentinel lymph node (SLN) biopsy emerged as a method to assess axillary nodal status and possibly obviate the need for ALND in patients with clinically node-negative (cN0) breast cancer. The majority of breast cancer patients are eligible for SLN biopsy only, so ALND can be avoided. However, there are subsets of patients in whom ALND cannot be eliminated. ALND is still needed in patients with three or more positive SLNs or those with gross extranodal or matted nodal disease. Moreover, ALND has conventionally been performed to establish local control in clinically node-positive (cN+) patients with a heavy axillary tumor burden. The sole method to avoid ALND is through neoadjuvant chemotherapy (NAC). Recently, various forms of conservative axillary surgery have been developed in order to minimize arm lymphedema without increasing axillary recurrence. In the era of effective multimodality therapy, conventional ALND may not be necessary in either cN0 or cN+ patients. Further studies with a longer follow-up period are needed to determine the safety of conservative axillary surgery.
Collapse
Affiliation(s)
- Masakuni Noguchi
- Department of Breast and Endocrine Surgery, Breast Center, Kanazawa Medical University Hospital, Daigaku-1-1, Uchinada, Kahoku 920-0293, Ishikawa, Japan; (M.I.); (M.Y.-N.); (E.M.); (Y.H.)
| | | | | | | | | |
Collapse
|
4
|
Brown S, Dayan JH, Kataru RP, Mehrara BJ. The Vicious Circle of Stasis, Inflammation, and Fibrosis in Lymphedema. Plast Reconstr Surg 2023; 151:330e-341e. [PMID: 36696336 PMCID: PMC9881755 DOI: 10.1097/prs.0000000000009866] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
SUMMARY Lymphedema is a progressive disease of the lymphatic system arising from impaired lymphatic drainage, accumulation of interstitial fluid, and fibroadipose deposition. Secondary lymphedema resulting from cancer treatment is the most common form of the disease in developed countries, affecting 15% to 40% of patients with breast cancer after lymph node dissection. Despite recent advances in microsurgery, outcomes remain variable and, in some cases, inadequate. Thus, development of novel treatment strategies is an important goal. Research over the past decade suggests that lymphatic injury initiates a chronic inflammatory response that regulates the pathophysiology of lymphedema. T-cell inflammation plays a key role in this response. In this review, the authors highlight the cellular and molecular mechanisms of lymphedema and discuss promising preclinical therapies.
Collapse
Affiliation(s)
- Stav Brown
- From the Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center
| | - Joseph H Dayan
- From the Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center
| | - Raghu P Kataru
- From the Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center
| | - Babak J Mehrara
- From the Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center
| |
Collapse
|
5
|
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: 5] [Impact Index Per Article: 5.0] [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.
Collapse
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
| |
Collapse
|
6
|
Axillary reverse mapping using near-infrared fluorescence imaging in invasive breast cancer (ARMONIC study). EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:2393-2400. [PMID: 35840448 DOI: 10.1016/j.ejso.2022.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 07/04/2022] [Accepted: 07/04/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Axillary lymph node dissection (ALND) in patients with breast cancer has potential side effects, including upper-limb lymphedema. Axillary reverse mapping (ARM) is a technique that enables discrimination of the lymphatic drainage of the upper limb in the axillary lymph node basin from that of the breast. We aimed to evaluate ARM node identification by near-infrared (NIR) fluorescence imaging during total mastectomy with ALND and then to analyze potential predictive factors of ARM node involvement. METHODS The study enrolled 119 patients diagnosed with invasive breast cancer with an indication for ALND. NIR imaging using indocyanine green dye was performed in 109 patients during standard ALND to identify ARM nodes and their corresponding lymphatic ducts. RESULTS 94.5% of patients had ARM nodes identified (95%CI = [88.4-98.0]). The ARM nodes were localized in zone D in 63.4% of cases. Metastatic axillary lymph nodes were found in 55% in the whole cohort, and 19.4% also had metastasis in ARM nodes. Two patients had metastatic ARM nodes but not in the remaining axillary lymph nodes. No serious adverse events were observed. Only the amount of mitosis was significantly associated with ARM node metastasis. CONCLUSIONS ARM by NIR fluorescence imaging could be a reliable technique to identify ARM nodes in real-time when ALND is performed. The clinical data compared with ARM node histological diagnosis showed only the amount of mitosis in the diagnostic biopsy is a potential predictive factor of ARM node involvement. CLINICAL TRIAL REGISTRATION NCT02994225.
Collapse
|
7
|
Brown S, Dayan JH, Coriddi M, Campbell A, Kuonqui K, Shin J, Park HJ, Mehrara BJ, Kataru RP. Pharmacological Treatment of Secondary Lymphedema. Front Pharmacol 2022; 13:828513. [PMID: 35145417 PMCID: PMC8822213 DOI: 10.3389/fphar.2022.828513] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 01/07/2022] [Indexed: 12/12/2022] Open
Abstract
Lymphedema is a chronic disease that results in swelling and decreased function due to abnormal lymphatic fluid clearance and chronic inflammation. In Western countries, lymphedema most commonly develops following an iatrogenic injury to the lymphatic system during cancer treatment. It is estimated that as many as 10 million patients suffer from lymphedema in the United States alone. Current treatments for lymphedema are palliative in nature, relying on compression garments and physical therapy to decrease interstitial fluid accumulation in the affected extremity. However, recent discoveries have increased the hopes of therapeutic interventions that may promote lymphatic regeneration and function. The purpose of this review is to summarize current experimental pharmacological strategies in the treatment of lymphedema.
Collapse
|
8
|
Isik A, Soran A, Grasi A, Barry N, Sezgin E. Lymphedema after Sentinel Lymph Node Biopsy: Who is at Risk? Lymphat Res Biol 2021; 20:160-163. [PMID: 34191608 DOI: 10.1089/lrb.2020.0093] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Aim: Sentinel lymph node biopsy (SLNB) is the accepted approach to stage the clinically negative axilla. The incidence of lymphedema (LE) after SLNB is about 5%. We hypothesize that patients undergoing axillary excision of >5 lymph nodes (LNs) are at increased risk of developing LE. Methods and Results: A single institution prospective breast cancer database was retrospectively reviewed from January 2013 to December 2017, to identify patients who underwent SLNB and were diagnosed with LE. Inclusion criteria was (1) de novo breast cancer, (2) SLNB in clinically node negative patients, and (3) no preoperative diagnosis LE of an extremity. Exclusion criteria was history of axillary lymph node dissection. Age, body mass index, tumor-node-metastasis status, surgery type, neoadjuvant or adjuvant chemotherapy, radiotherapy, and hormone therapy were analyzed. Of the 3325 patients identified, 2940 patients met the inclusion criteria and were included in the final analysis. Median follow-up time was 24 months. Forty-seven (2%) patients were diagnosed with LE, and nine patients (19%) had >5 LNs excised. LE was diagnosed in 3.7% of patients who had >5 LNs excised versus 1.4% of patients with ≤5 LNs excised. Incidence of LE was higher in patients with >5 LNs excision (p = 0.006). Conclusion: Our study showed that patients have a higher likelihood of developing LE when >5 LNs are excised.
Collapse
Affiliation(s)
- Arda Isik
- Department of Breast Surgery, Magee-Womens Hospital of UPMC, Pittsburgh, Pennsylvania, USA
| | - Atilla Soran
- Department of Breast Surgery, Magee-Womens Hospital of UPMC, Pittsburgh, Pennsylvania, USA
| | - Ariel Grasi
- Department of Breast Surgery, Magee-Womens Hospital of UPMC, Pittsburgh, Pennsylvania, USA
| | - Noran Barry
- Department of Breast Surgery, Magee-Womens Hospital of UPMC, Pittsburgh, Pennsylvania, USA
| | - Efe Sezgin
- Department of Food Engineering, Laboratory of Nutrigenomics and Epidemiology, Izmir Institute of Technology, Urla, Izmir, Turkey
| |
Collapse
|
9
|
Shah C, Zambelli-Weiner A, Delgado N, Sier A, Bauserman R, Nelms J. The impact of monitoring techniques on progression to chronic breast cancer-related lymphedema: a meta-analysis comparing bioimpedance spectroscopy versus circumferential measurements. Breast Cancer Res Treat 2020; 185:709-740. [PMID: 33245458 PMCID: PMC7921068 DOI: 10.1007/s10549-020-05988-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 10/20/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Chronic breast cancer-related lymphedema (BCRL) is a potentially serious complication following treatment. Monitoring for progression to BCRL may allow for earlier detection and intervention, reducing the rate of progression to chronic BCRL. Therefore, the purpose of this meta-analysis is to evaluate the impact of monitoring techniques on the incidence of chronic BCRL among patients monitored by bioimpedance spectroscopy (BIS) and circumference as compared to background rates. METHODS Eligible peer-reviewed studies from PubMed, CINHAL, or Google Scholar that were published in English from 2013 onward and conducted in North America, Europe, or Oceania. Incidence rates abstracted from studies were classified by BCRL monitoring method: background (no standardized BIS or circumference assessments), BIS or circumference. A random-effects model was used to calculate a pooled annualized estimate of BCRL incidence while accounting for clinical and methodological heterogeneity. Subgroup analyses examined differences in duration of follow-up as well as breast and axillary surgery. RESULTS 50 studies were included, representing over 67,000 women. The annualized incidence of BCRL was 4.9% (95% CI: 4.3-5.5) for background studies (n = 35), 1.5% (95% CI: 0.6-2.4) for BIS-monitored studies (n = 7), and 7.7% (95% CI: 5.6-9.8) for circumference-monitored studies (n = 11). The cumulative BCRL incidence rate in BIS-monitored patients was 3.1% as compared to 12.9% with background monitoring (69% reduction) and 17.0% with circumference-monitored patients (81% reduction). CONCLUSIONS Evidence suggests that monitoring with BIS allowing for early intervention significantly reduces the relative risk of chronic BCRL with a 69% and 81% reduction compared to background and circumference, respectively. Circumference monitoring did not appear to provide a benefit with respect to chronic BCRL incidence. Based on these results, BIS should be considered for BCRL screening in order to detect subclinical BCRL and reduce rates of chronic BCRL, particularly in high-risk patients.
Collapse
Affiliation(s)
- Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.
| | | | | | - Ashley Sier
- TTi Health Research and Economics, Westminster, MD, USA
| | | | - Jerrod Nelms
- TTi Health Research and Economics, Westminster, MD, USA
| |
Collapse
|
10
|
Noguchi M, Inokuchi M, Noguchi M, Morioka E, Ohno Y, Kurita T. Axillary surgery for breast cancer: past, present, and future. Breast Cancer 2020; 28:9-15. [PMID: 33165758 DOI: 10.1007/s12282-020-01120-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 06/08/2020] [Indexed: 02/06/2023]
Abstract
In breast cancer surgery, there has been a major shift toward less invasive local treatment. Although axillary lymph node dissection (ALND) was an integral part of surgical treatment for breast cancer, sentinel lymph node (SLN) biopsy was developed as an accurate method for axillary staging. ALND can be avoided not only in patients with negative SLNs but also in those with one or two positive SLNs receiving breast and/or axillary radiation. On the other hand, ALND has remained the standard treatment for patients with clinically positive nodes. However, axillary reverse mapping (ARM) was developed to map and preserve arm lymphatic drainage during ALND and/or SLN biopsy. This procedure allowed reduction of the rate of arm lymphedema without increasing axillary recurrence, although patients receive postoperative chemotherapy and high-risk patients undergo axillary radiation. Standard ALND may not be necessary even for patients with clinically positive nodes who receive axillary radiation and systemic therapy. Thus, the extent of axillary surgery in breast cancer has been decreased with increased use of systemic and radiation therapy.
Collapse
Affiliation(s)
- Masakuni Noguchi
- Breast Center, Kanazawa Medical University Hospital, Ishikawa, Japan. .,Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku 1-1, Uchinada, Ishikawa, 920-0293, Japan.
| | - Masafumi Inokuchi
- Breast Center, Kanazawa Medical University Hospital, Ishikawa, Japan.,Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku 1-1, Uchinada, Ishikawa, 920-0293, Japan
| | - Miki Noguchi
- Breast Center, Kanazawa Medical University Hospital, Ishikawa, Japan.,Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku 1-1, Uchinada, Ishikawa, 920-0293, Japan
| | - Emi Morioka
- Breast Center, Kanazawa Medical University Hospital, Ishikawa, Japan.,Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku 1-1, Uchinada, Ishikawa, 920-0293, Japan
| | - Yukako Ohno
- Breast Center, Kanazawa Medical University Hospital, Ishikawa, Japan.,Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku 1-1, Uchinada, Ishikawa, 920-0293, Japan
| | - Tomoko Kurita
- Department of Breast Surgery, Nippon Medical School Hospital, Tokyo, Japan
| |
Collapse
|
11
|
Noguchi M, Inokuchi M, Noguchi M, Morioka E, Kurita T. Axillary reverse mapping in patients undergoing axillary dissection -a short review of the literature. Eur J Surg Oncol 2020; 46:2218-2220. [PMID: 32912671 DOI: 10.1016/j.ejso.2020.07.026] [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: 06/29/2020] [Revised: 07/09/2020] [Accepted: 07/17/2020] [Indexed: 11/28/2022] Open
Abstract
Axillary lymph node dissection (ALND) can be avoided not only in patients with negative sentinel lymph nodes (SLNs) but also in those with one or two positive SLNs receiving breast or axillary radiation. However, ALND has remained the standard treatment for patients with clinically positive nodes (cN+). Although axillary reverse mapping (ARM) was developed to map and preserve arm lymphatic drainage during ALND, it could not be indicated for cN + patients because metastatic rate of ARM nodes is high. However, a new type of conservative ALND with ARM attempts to preserve ARM lymphatics and nodes except SLNs and other suspicious palpable nodes, including suspicious ARM nodes. This procedure allowed reduction of the rate of arm lymphedema without increasing axillary recurrence, although patients received postoperative chemotherapy and high-risk patients underwent axillary radiation. Thus, a traditional full ALND may not be necessary for cN + patients in the era of effective multimodality therapy.
Collapse
Affiliation(s)
- Masakuni Noguchi
- Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Ishikawa, Japan; Breast Center, Kanazawa Medical University Hospital, Ishikawa, Japan.
| | - Masafumi Inokuchi
- Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Ishikawa, Japan; Breast Center, Kanazawa Medical University Hospital, Ishikawa, Japan
| | - Miki Noguchi
- Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Ishikawa, Japan; Breast Center, Kanazawa Medical University Hospital, Ishikawa, Japan
| | - Emi Morioka
- Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Ishikawa, Japan; Breast Center, Kanazawa Medical University Hospital, Ishikawa, Japan
| | - Tomoko Kurita
- Department of Breast Surgery, Nippon Medical School Hospital, Tokyo, Japan
| |
Collapse
|
12
|
Chen K, Liu J, Li S, Jacobs L. Development of nomograms to predict axillary lymph node status in breast cancer patients. BMC Cancer 2017; 17:561. [PMID: 28835223 PMCID: PMC5569510 DOI: 10.1186/s12885-017-3535-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 08/03/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Prediction of axillary lymph node (ALN) status preoperatively is critical in the management of breast cancer patients. This study aims to develop a new set of nomograms to accurately predict ALN status. METHODS We searched the National Cancer Database to identify eligible female breast cancer patients with profiles containing critical information. Patients diagnosed in 2010-2011 and 2012-2013 were designated the training (n = 99,618) and validation (n = 101,834) cohorts, respectively. We used binary logistic regression to investigate risk factors for ALN status and to develop a new set of nomograms to determine the probability of having any positive ALNs and N2-3 disease. We used ROC analysis and calibration plots to assess the discriminative ability and accuracy of the nomograms, respectively. RESULTS In the training cohort, we identified age, quadrant of the tumor, tumor size, histology, ER, PR, HER2, tumor grade and lymphovascular invasion as significant predictors of ALNs status. Nomogram-A was developed to predict the probability of having any positive ALNs (P_any) in the full population with a C-index of 0.788 and 0.786 in the training and validation cohorts, respectively. In patients with positive ALNs, Nomogram-B was developed to predict the conditional probability of having N2-3 disease (P_con) with a C-index of 0.680 and 0.677 in the training and validation cohorts, respectively. The absolute probability of having N2-3 disease can be estimated by P_any*P_con. Both of the nomograms were well-calibrated. CONCLUSIONS We developed a set of nomograms to predict the ALN status in breast cancer patients.
Collapse
Affiliation(s)
- Kai Chen
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
- Breast Tumor Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong 510120 China
| | - Jieqiong Liu
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
- Breast Tumor Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong 510120 China
| | - Shunrong Li
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
- Breast Tumor Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong 510120 China
| | - Lisa Jacobs
- Departments of Surgery and Oncology, Johns Hopkins Medical Institutions, Blalock #607, 600 N. Wolfe St, Baltimore, Maryland 21287 USA
| |
Collapse
|
13
|
Lai L, Binkley J, Jones V, Kirkpatrick S, Furbish C, Stratford P, Thompson W, Sidhu A, Farley C, Okoli J, Beech D, Gabram S. Implementing the Prospective Surveillance Model (PSM) of Rehabilitation for Breast Cancer Patients with 1-Year Postoperative Follow-up, a Prospective, Observational Study. Ann Surg Oncol 2016; 23:3379-84. [DOI: 10.1245/s10434-016-5315-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Indexed: 11/18/2022]
|
14
|
Kenny TC, Dove J, Shabahang M, Woll N, Hunsinger M, Morgan A, Blansfield J. Widespread Implications of ACOSOG Z0011: Effect on Total Mastectomy Patients. Am Surg 2016. [DOI: 10.1177/000313481608200124] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The ACOSOG Z0011 trial demonstrated that axillary lymph node dissection (ALND) is not necessary for all breast cancer patients. Patients who underwent breast conservation surgery (BCS) or total mastectomy (TM) and met Z0011 criteria were identified and sorted into pre- and post-Z0011 cohorts. Four hundred ninety four patients had breast cancer surgery from July 2008 to February 2013. Of these, 255 were pre-Z0011 and 239 were post. Pre-Z0011, 14 patients met Z0011 inclusion criteria in BCS subgroup. ALND was performed in 10 of these patients (71%). Post-Z0011, 14 patients met inclusion criteria, only 1 received ALND (7%). The decrease in ALND rate was significant (p=0.001). Pre-Z0011, 28 patients in TM subgroup met extrapolated inclusion criteria, twenty-three of which received ALND (82%). Post-Z0011, 14 patients in TM subgroup met extrapolated criteria, five of which underwent ALND (36%). The decrease in rate of ALND was significant (p=0.005). This study demonstrates that the Z0011 trial significantly altered management of the axilla in all breast cancer patients with positive sentinel lymph nodes, not just those receiving BCS.
Collapse
Affiliation(s)
| | - James Dove
- Geisinger Medical Center, Danville, Pennsylvania
| | | | - Nicole Woll
- Geisinger Medical Center, Danville, Pennsylvania
| | | | - April Morgan
- Geisinger Medical Center, Danville, Pennsylvania
| | | |
Collapse
|
15
|
Voss RK, Cromwell KD, Chiang YJ, Armer JM, Ross MI, Lee JE, Gershenwald JE, Stewart BR, Shaitelman SF, Cormier JN. The long-term risk of upper-extremity lymphedema is two-fold higher in breast cancer patients than in melanoma patients. J Surg Oncol 2015; 112:834-40. [PMID: 26477877 DOI: 10.1002/jso.24068] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 10/01/2015] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND OBJECTIVES We assessed the cumulative incidence, symptoms, and risk factors for upper-extremity lymphedema in breast cancer and melanoma patients undergoing sentinel lymph node biopsy or axillary lymph node dissection. METHODS Patients were recruited preoperatively (time 0) and assessed at 6, 12, and 18 months postoperatively. Limb volume change (LVC) was measured by perometry. Lymphedema was categorized as none, mild (LVC 5-9.9%), or moderate/severe (LVC≥10%). Symptoms were assessed with a validated lymphedema instrument. Longitudinal logistic regression analyses were conducted to identify risk factors associated with moderate/severe lymphedema. RESULTS Among 205 breast cancer and 144 melanoma patients, the cumulative incidence of moderate/severe lymphedema at 18 months was 36.5% and 35.0%, respectively. However, in adjusted analyses, factors associated with moderate/severe lymphedema were breast cancer (OR 2.0, P = 0.03), body mass index ≥ 30 kg/m(2) (OR 1.6, P = 0.04), greater number of lymph nodes removed (OR 1.05, P < 0.01), and longer interval since surgery (OR 2.33 at 18 months, P < 0.01). CONCLUSIONS Lymphedema incidence increased over time in both cohorts. However, the adjusted risk of moderate/severe lymphedema was two-fold higher in breast cancer patients. These results may be attributed to surgical treatment of the primary tumor in the breast and more frequent use of radiation.
Collapse
Affiliation(s)
- Rachel K Voss
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kate D Cromwell
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Yi-Ju Chiang
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jane M Armer
- Sinclair School of Nursing, University of Missouri, Columbia, Missouri
| | - Merrick I Ross
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jeffrey E Lee
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jeffrey E Gershenwald
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Bob R Stewart
- Sinclair School of Nursing, University of Missouri, Columbia, Missouri
| | - Simona F Shaitelman
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Janice N Cormier
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| |
Collapse
|
16
|
Outcomes with and without axillary node dissection for node-positive lumpectomy and mastectomy patients. Am J Surg 2015. [DOI: 10.1016/j.amjsurg.2015.05.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
17
|
Toi M, Winer EP, Benson JR, Inamoto T, Forbes JF, von Minckwitz G, Robertson JFR, Grobmyer SR, Jatoi I, Sasano H, Kunkler I, Ho AY, Yamauchi C, Chow LWC, Huang CS, Han W, Noguchi S, Pegram MD, Yamauchi H, Lee ES, Larionov AA, Bevilacqua JLB, Yoshimura M, Sugie T, Yamauchi A, Krop IE, Noh DY, Klimberg VS. Personalization of loco-regional care for primary breast cancer patients (part 1). Future Oncol 2015; 11:1297-300. [DOI: 10.2217/fon.15.65] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
ABSTRACT Kyoto Breast Cancer Consensus Conference, Kyoto, Japan, 18–20 February 2014 The loco-regional management of breast cancer is increasingly complex with application of primary systemic therapies, oncoplastic techniques and genetic testing for breast cancer susceptibility. Personalization of loco-regional treatment is integral to optimization of breast cancer care. Clinical and pathological tumor stage, biological features and host factors influence loco-regional treatment strategies and extent of surgical procedures. Key issues including axillary staging, axillary treatment, radiation therapy, primary systemic therapy (PST), preoperative hormonal therapy and genetic predisposition were identified and discussed at the Kyoto Breast Cancer Consensus Conference (KBCCC2014). In the first of a two part conference scene, consensus recommendations for axillary management are presented and focus on the following topics: indications for completion axillary lymph node dissection in primary surgical patients with ≤2 macrometastases or any sentinel nodal deposits after PST; the timing of sentinel lymph node biopsy in the context of PST; use of axillary irradiation as a component of primary treatment plans and the role of intraoperative node assessment in the post-Z0011 era.
Collapse
Affiliation(s)
- Masakazu Toi
- Breast Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawara-cho, Sakyo-ku, Kyoto 606–8507, Japan
| | - Eric P Winer
- Breast Oncology Center, Dana-Farber Cancer Institute, Brigham & Women's Cancer Center, Harvard Medical School, Boston, MA 02215, USA
| | - John R Benson
- Cambridge Breast Unit, Addenbrooke's Hospital & University of Cambridge, Cambridge, UK
| | - Takashi Inamoto
- Faculty of Health Care, Tenri Health Care University, Nara, Japan
| | - John F Forbes
- Surgical Oncology, University of Newcastle, Newcastle, Australia
| | | | - John FR Robertson
- Breast Surgery, University of Nottingham, Royal Derby Hospital, Nottingham, UK
| | - Stephen R Grobmyer
- Cleveland Clinic & Lerner College of Medicine of Case Western Reserve University, Cleveland, OH 44195, USA
| | - Ismail Jatoi
- The University of Texas Health Science Center, San Antonio, TX 78229, USA
| | - Hironobu Sasano
- Pathology, Tohoku University School of Medicine, Sendai, Japan
| | - Ian Kunkler
- Edinburgh Cancer Research UK Centre, The University of Edinburgh, UK
| | - Alice Y Ho
- Radiation Oncology, Memorial Sloan–Kettering Cancer Center, NY 10065, USA
| | - Chikako Yamauchi
- Radiation Oncology, Shiga Medical Center for Adults, Moriyama, Japan
| | - Louis WC Chow
- UNIMED Medical Institute/University of Hong Kong, Hong Kong
| | - Chiun-Sheng Huang
- Surgery, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Wonshik Han
- Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Shinzaburo Noguchi
- Breast & Endocrine Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Mark D Pegram
- Stanford Cancer Institute, School of Medicine, Stanford University, CA 94305, USA
| | | | - Eun-Sook Lee
- Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Alexey A Larionov
- Statistics & Computational Biology Laboratory, University of Cambridge, Cancer Research UK Cambridge Institute, UK
| | - Jose LB Bevilacqua
- Department of Breast Surgery, AC Camargo Cancer Center, Sao Paulo, Brazil
| | - Michio Yoshimura
- Radiation Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | | | - Akira Yamauchi
- Breast Center, Kitano Hospital, The Tazuke Kofukai Medical Research Institute, Osaka, Japan
| | - Ian E Krop
- Breast Oncology Center, Dana-Farber Cancer Institute, Brigham & Women's Cancer Center, Harvard Medical School, Boston, MA 02215, USA
| | - Dong Young Noh
- Surgery, Seoul National University Hospital, Seoul, South Korea
| | - V Suzanne Klimberg
- Surgery, Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, AR 72205, USA
| | | |
Collapse
|
18
|
Krok-Schoen JL, Oliveri JM, Kurta ML, Paskett ED. Breast cancer-related lymphedema: risk factors, prevention, diagnosis and treatment. BREAST CANCER MANAGEMENT 2015. [DOI: 10.2217/bmt.14.51] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Lymphedema is one of the late effects of breast cancer treatment that affects many breast cancer survivors. Despite an increased focus on morbidity among this survivor population, our understanding of risk reduction, prevention, diagnosis and treatment of lymphedema remain poorly understood. This article provides an overview of the current state of the research (2009–2014) on breast cancer-related lymphedema and offers future directions for research. A greater emphasis must be placed on reducing the impact of lymphedema to improve the quality of life for breast cancer survivors.
Collapse
Affiliation(s)
- Jessica L Krok-Schoen
- Comprehensive Cancer Center, The Ohio State University, 1590 N High Street, Suite 525, Columbus, OH 43201, USA
| | - Jill M Oliveri
- Comprehensive Cancer Center, The Ohio State University, 1590 N High Street, Suite 525, Columbus, OH 43201, USA
| | | | - Electra D Paskett
- Comprehensive Cancer Center, The Ohio State University, 1590 N High Street, Suite 525, Columbus, OH 43201, USA
- Division of Cancer Prevention & Control, Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, OH 43210, USA
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH 43210, USA
| |
Collapse
|
19
|
Noble-Jones R, Fitzpatrick B, Sneddon MC, Hendry DS, Leung HY. Development of the lymphoedema genito-urinary cancer questionnaire. ACTA ACUST UNITED AC 2014; 23 Suppl 18:S14-9. [PMID: 25302997 DOI: 10.12968/bjon.2014.23.sup18.s14] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The aim of this study was to develop a patient self-report tool to detect symptoms of genital and lower limb lymphoedema in male survivors of genitourinary cancer. The study incorporated the views of patients and subject specialists (lymphoedema and urology) in the design of a patient questionnaire based on the literature. Views on comprehensiveness, relevance of content, ease of understanding and perceived acceptability to patients were collated. The findings informed the development of the next iteration of the questionnaire. The overall view of participants was that the development and application of such a tool was of great clinical value and the Lymphoedema Genito-Urinary Cancer Questionnaire (LGUCQ) has significant potential for further development as a research tool to inform prevalence of this under-reported condition.
Collapse
Affiliation(s)
- Rhian Noble-Jones
- University Teacher, University of Glasgow and Oncology Physiotherapist, Western General Hospital, Edinburgh
| | | | | | | | | |
Collapse
|