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Koelmeyer LA, Gaitatzis K, Dietrich MS, Shah CS, Boyages J, McLaughlin SA, Taback B, Stolldorf DP, Elder E, Hughes TM, French JR, Ngui N, Hsu JM, Moore A, Ridner SH. Risk factors for breast cancer-related lymphedema in patients undergoing 3 years of prospective surveillance with intervention. Cancer 2022; 128:3408-3415. [PMID: 35797441 PMCID: PMC9542409 DOI: 10.1002/cncr.34377] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 03/30/2022] [Accepted: 04/01/2022] [Indexed: 12/30/2022]
Abstract
Background To evaluate risk factors (treatment‐related, comorbidities, and lifestyle) for breast cancer–related lymphedema (BCRL) within the context of a Prospective Surveillance and Early Intervention (PSEI) model of care for subclinical BCRL. Methods The parent randomized clinical trial assigned patients newly diagnosed with breast cancer to PSEI with either bioimpedance spectroscopy (BIS) or tape measurement (TM). Surgical, systemic and radiation treatments, comorbidities, and lifestyle factors were recorded. Detection of subclinical BCRL (change from baseline of either BIS L‐Dex ≥6.5 or tape volume ≥ 5% and < 10%) triggered an intervention with compression therapy. Volume change from baseline ≥10% indicated progression to chronic lymphedema and need for complex decongestive physiotherapy. In this secondary analysis, multinomial logistic regressions including main and interaction effects of the study group and risk factors were used to test for factor associations with outcomes (no lymphedema, subclinical lymphedema, progression to chronic lymphedema after intervention, progression to chronic lymphedema without intervention). Post hoc tests of significant interaction effects were conducted using Bonferroni‐corrected alphas of .008; otherwise, an alpha of .05 was used for statistical significance. Results The sample (n = 918; TM = 457; BIS = 461) was female with a median age of 58.4 years. Factors associated with BCRL risk included axillary lymph node dissection (ALND) (p < .001), taxane‐based chemotherapy (p < .001), regional nodal irradiation (RNI) (p ≤ .001), body mass index >30 (p = .002), and rurality (p = .037). Mastectomy, age, hypertension, diabetes, seroma, smoking, and air travel were not associated with BCRL risk. Conclusions Within the context of 3 years of PSEI for subclinical lymphedema, variables of ALND, taxane‐based chemotherapy, RNI, body mass index >30, and rurality increased risk. The Prospective Surveillance and Early Intervention Model promotes identification and treatment of subclinical lymphedema, facilitating prevention of chronic lymphedema and risk reduction. Axillary lymph node dissection, taxane‐based chemotherapy, regional nodal irradiation, body mass index >30, and rurality are critical risk factors within the context of the Prospective Surveillance and Early Intervention Model for some patients.
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Affiliation(s)
- Louise A Koelmeyer
- Australian Lymphoedema Education, Research, and Treatment (ALERT) Program, Faculty Medicine, Health & Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Katrina Gaitatzis
- Australian Lymphoedema Education, Research, and Treatment (ALERT) Program, Faculty Medicine, Health & Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Mary S Dietrich
- Vanderbilt University School of Nursing, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Chirag S Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - John Boyages
- Australian Lymphoedema Education, Research, and Treatment (ALERT) Program, Faculty Medicine, Health & Human Sciences, Macquarie University, Sydney, New South Wales, Australia.,Icon Cancer Centre, Sydney, New South Wales, Australia
| | | | - Bret Taback
- Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Deonni P Stolldorf
- Vanderbilt University School of Nursing, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Elisabeth Elder
- Westmead Breast Cancer Institute, Westmead, New South Wales, Australia.,The University of Sydney, Sydney, New South Wales, Australia.,Lakeside Specialist Breast Clinic, Norwest, New South Wales, Australia
| | - T Michael Hughes
- ANU Clinical School at Sydney Adventist Hospital, Australian National University, Canberra, Australia
| | - James R French
- Westmead Breast Cancer Institute, Westmead, New South Wales, Australia.,The University of Sydney, Sydney, New South Wales, Australia.,Lakeside Specialist Breast Clinic, Norwest, New South Wales, Australia
| | - Nicholas Ngui
- Northern Surgical Oncology, Sydney Adventist Hospital, Wahroonga, New South Wales, Australia
| | - Jeremy M Hsu
- Westmead Breast Cancer Institute, Westmead, New South Wales, Australia.,Lakeside Specialist Breast Clinic, Norwest, New South Wales, Australia.,Macquarie University, Macquarie, Park, New South Wales, Australia
| | - Andrew Moore
- Southeast Cancer Center, Cape Girardeau, Missouri, USA
| | - Sheila H Ridner
- Vanderbilt University School of Nursing, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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The Lymph-Sparing Quotient: A Retrospective Risk Analysis on Extremity Radiation for Soft Tissue Sarcoma Treatment. Cancers (Basel) 2021; 13:cancers13092113. [PMID: 33925683 PMCID: PMC8125651 DOI: 10.3390/cancers13092113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 04/22/2021] [Accepted: 04/24/2021] [Indexed: 01/06/2023] Open
Abstract
Simple Summary Soft tissue sarcomas, a heterogenous group of tumors with a mesenchymal origin, are mostly located in the extremities and are commonly treated with surgery and radiotherapy. Using opportunities of reducing long-term therapy-related side effects in soft tissue sarcoma treatment is an important task for all physicians involved in soft tissue sarcoma treatment. The extent of lymph-sparing volume in adjuvant radiation therapy of extremity soft tissue sarcoma as a risk factor for lymphedema was analyzed in this study. Patients with a low lymph-sparing volume showed an increased risk of lymphedema in this retrospective study. Maximizing the potential oncologically justifiable lymph-sparing volume should be considered to reduce the risk of high-grade lymphedema when applying RT to extremities. Abstract Radiation therapy (RT) for extremity soft tissue sarcoma is associated with lymphedema risk. In this study, we analyzed the influence of lymph-sparing volume on the lymphedema occurrence in patients who received adjuvant extremity RT. The lymph-sparing quotient (LSQ) was calculated by dividing the lymph-sparing volume by the total extremity volume with double weightingfor the narrowest lymph-sparing region. A total of 34 patients were enrolled in this analysis. The median applied total radiation dose was 66.3 Gy in 36 fractions. Acute lymphedema appeared in 12 patients (35%). Most of them (n = 8) were lymphedema grade 1 and five patients had grade 2 to 3 lymphedema. Chronic lymphedema appeared in 22 patients (65%). 17 of these patients had at least a grade 2 lymphedema. In 13 of 14 patients with an LSQ ≤ 0.2 and 11 of 20 patients with an LSQ > 0.2, an acute or chronic lymphedema ≥ grade 2 was observed. A Kaplan–Meier Analysis of the two groups with the endpoint of a two-year lymph edema-free survival (=2-YLEFS) was estimated with an univariate, significant result (2-YLEFS LSQ ≤ 0.2 vs. LSQ > 0.2: 0% vs. 39%; p = 0.006; hazard ratio LSQ ≤ 0.2 vs. > 0.2 2-YLEFS 2.822 (p = 0.013); 95% confidence interval (CI): 1.24–6.42). Maximizing the potential oncologically-justifiable lymph-sparing volume should be considered to reduce the risk of high-grade lymphedema when applying RT to extremities.
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Fuzzard SK, Mah E, Choong PFM, Grinsell D. Lymphoedema rates in pedicled anterolateral thigh flaps for coverage of irradiated groin defects. ANZ J Surg 2019; 90:135-138. [PMID: 31840376 DOI: 10.1111/ans.15576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 09/30/2019] [Accepted: 10/14/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Limb salvage surgery in conjunction with adjuvant radiotherapy is the preferred treatment for soft tissue sarcoma. This study aims to determine if ipsilateral pedicled anterolateral thigh (ALT) flap reconstruction of groin defects post soft tissue sarcoma resection results in acceptable rates of lymphoedema, while also providing good soft tissue cover and minimal donor site morbidity. METHODS A retrospective chart audit was conducted with ethics approval, obtaining a case series of 16 patients operated on at a single institution by the senior surgeon. Patients who underwent ipsilateral pedicled ALT flap coverage of irradiated groin defects following soft tissue sarcoma resection were included. Comparative six-point limb circumference measurements were utilized to diagnose lymphoedema, with a difference of 10% when compared to the non-operative side being deemed significant. RESULTS Lymphoedema was noted in three patients (18.8%) with an average follow-up period of 40.9 (range 8-59) months. CONCLUSION Previously published lymphoedema rates in sarcoma limb salvage surgery of 15.5-30% are comparable to the rates obtained in this cohort. Lymphoedema rates do not appear to be higher in patients undergoing ipsilateral pedicled ALT flap reconstruction, thus making it a useful soft tissue coverage technique in this cohort.
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Affiliation(s)
- Sibon K Fuzzard
- Department of Plastic and Reconstructive Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Eldon Mah
- Department of Plastic and Reconstructive Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Peter F M Choong
- Department of Orthopaedic Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Damien Grinsell
- Department of Plastic and Reconstructive Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia
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Kobayashi H, Iida T, Yamamoto T, Ikegami M, Shinoda Y, Tanaka S, Kawano H. Lymphaticovenous Anastomoses for Lymphedema Complicated by Severe Lymphorrhea Following Resection of Soft-Tissue Sarcomas of the Adductor Compartment: A Report of Two Cases. JBJS Case Connect 2017; 7:e80. [PMID: 29286964 DOI: 10.2106/jbjs.cc.17.00078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
CASE Lymphedema and lymphorrhea are major causes of wound complications after the resection of soft-tissue sarcomas in the adductor compartment of the thigh. We report 2 cases of successful treatment of lymphedema and lymphorrhea, which had been refractory to nonoperative treatment, with use of lymphaticovenous anastomosis (LVA) and intraoperative indocyanine green lymphography after the resection of a sarcoma in the adductor compartment. CONCLUSION These 2 cases highlight that LVA can be a useful and minimally invasive alternative to myocutaneous flaps for the treatment of wound complications caused by lymphedema and lymphorrhea after surgery for soft-tissue sarcomas in the adductor compartment of the thigh.
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Affiliation(s)
- Hiroshi Kobayashi
- Departments of Orthopaedic Surgery (H.K., M.I., Y.S., and S.T.) and Plastic and Reconstructive Surgery (T.I. and T.Y.), Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - Takuya Iida
- Departments of Orthopaedic Surgery (H.K., M.I., Y.S., and S.T.) and Plastic and Reconstructive Surgery (T.I. and T.Y.), Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - Takumi Yamamoto
- Departments of Orthopaedic Surgery (H.K., M.I., Y.S., and S.T.) and Plastic and Reconstructive Surgery (T.I. and T.Y.), Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - Masachika Ikegami
- Departments of Orthopaedic Surgery (H.K., M.I., Y.S., and S.T.) and Plastic and Reconstructive Surgery (T.I. and T.Y.), Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - Yusuke Shinoda
- Departments of Orthopaedic Surgery (H.K., M.I., Y.S., and S.T.) and Plastic and Reconstructive Surgery (T.I. and T.Y.), Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - Sakae Tanaka
- Departments of Orthopaedic Surgery (H.K., M.I., Y.S., and S.T.) and Plastic and Reconstructive Surgery (T.I. and T.Y.), Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - Hirotaka Kawano
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Teikyo, Tokyo, Japan
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