Risk factors of lymph edema in breast cancer patients

The Effects of Daily-Living Risks on Breast Cancer-Related Lymphedema

BACKGROUND

Conventional advice to reduce the risk of breast cancer-related lymphedema (BCLE) suggests avoidance of daily-living risks, and limited research has investigated these risks.

OBJECTIVE

This study aimed to examine the occurrence, patterns, and effects of daily-living risks on BCLE.

METHODS

A cross-sectional design was used to collect data from 567 patients at a metropolitan cancer center in the United States. The Lymphedema Risk-Reduction Behavior Checklist was used to assess the occurrence of 11 daily-living risks. Descriptive, regression, and factor analyses were performed.

RESULTS

Significant odds of BCLE were associated with infection (odds ratio [OR] 2.58, 95% confidence interval [CI] 1.95-3.42), cuts/scratches (OR 2.65, 95% CI 1.97-3.56), sunburn (OR 1.89, 95% CI 1.39-3.56), oil splash or steam burns (OR 2.08, 95% CI 1.53-3.83), and insect bites (OR 1.59, 95% CI 1.18-2.13). The daily-living risks were clustered into factors related to skin trauma and carrying objects. Skin trauma risk was significantly associated with BCLE (B = 0.539, z = 3.926, OR 1.714, 95% CI 1.312-2.250; p < 0.001). Having three, four, or five skin trauma risks significantly increased the odds of BCLE to 4.31, 5.14, and 6.94 times, respectively. The risk of carrying objects had no significant or incremental effects on BCLE.

CONCLUSION

Complete avoidance of daily-living risks is challenging given 52.73% of patients incurred more than five daily-living risks. Our study findings underscore the importance of 'what to do' strategies to minimize infection and skin trauma.

Current evidence on patient precautions for reducing breast cancer-related lymphedema manifestation and progression risks

Risk management and self-management strategies for breast cancer-related lymphedema (BCRL) must balance best-evidence guidelines and associated risk factor knowledge. There is an evidence-based practice gap in the understanding of whether a change in education about risk factors and whether behavioral changes actually influence BCRL manifestation or progression. The purpose of this study was to (1) review if current evidence supports or refutes patient precautions to prevent the manifestation and/or progression of BCRL, (2) review if behavioral changes result in the prevention or reduction of BCRL, and (3) identify related gaps of knowledge for future research. Evidence map methodology was used to systematically review literature related to reducing the risk of BCRL. Literature searches were conducted in Medline, CINAHL, and Cochrane for the categories of trauma, blood pressure, temperature, air travel, and behavior change. One hundred and forty-eight articles were included for full-text review, of which 37 articles were included in this study. Within the confines of limb and trunk circumferential and/or volume enlargement, a 'just in case' approach to patient education on risk factors may not be appropriate for breast cancer survivors at risk of manifesting lymphedema. Patient education about precautionary risks for the onset of BCRL needs to align with research evidence. There is scant evidence about the risks of BCRL progression suggesting a need for future research.

The influence of non-cancer-related risk factors on the development of cancer-related lymphedema: a rapid review

Extensive research supports an evidence-base for cancer treatment-related risk factors, including extent of lymph node dissection and use of radiotherapy, as contributing to secondary lymphedema. Additionally, comorbidities, such as higher body mass index, and vascular-related conditions are identified to further augment risk. While social determinants of health (SDOH) and socioeconomic factors are widely regarded as influencing an individual's healthcare outcomes, including cancer risk and survival, these factors have not been explored as risk factors for developing secondary lymphedema. A rapid literature review explored the current evidence for SDOH as risk factors for lymphedema. Studies that were published over the last 10 years and that specifically analyzed social factors as variables associated with lymphedema were included. Studies that only characterized the social determinants of the study population were not included. Forty-nine studies were identified through a rapid literature review, and 13 studies that expressly analyzed social determinants as risk factors for secondary lymphedema were reviewed and extracted. All studies were conducted in patients with breast cancer-related lymphedema. Social risk factors included race, educational level, insurance type, and income level. These are consistent with the socioeconomic inequalities related to cancer survival. SDOH may influence the risk of developing cancer treatment-related health conditions like secondary lymphedema. Research trials studying cancer treatment-related conditions should collect consistent and robust data across social, behavioral, environmental, and economic domains and should analyze these variables to understand their contribution to study endpoints. Risk prediction modeling could be a future pathway to better incorporate social determinants, along with medical and co-morbidity data, to holistically understand lymphedema risk.

Risk factors for long-term arm morbidities following breast cancer treatments: A systematic review

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.

Early Disturbance of Lymphatic Transport as a Risk Factor for the Development of Breast-Cancer-Related Lymphedema

Introduction: Breast-cancer-related lymphedema (BCRL) is a frequently occurring and debilitating condition. When lymphedema is diagnosed late, treatment can be expected to be less effective. Lymphofluoroscopy can provide details about the superficial lymphatic architecture and can detect an early disturbance of lymphatic transport (i.e., dermal backflow) before the lymphedema is clinically visible. The main objective of this study is to investigate whether this early disturbance of lymphatic transport visualized by lymphofluoroscopy is a risk factor for the development of BCRL. Methodology: All patients scheduled for unilateral breast cancer surgery with axillary lymph node dissection or sentinel node biopsy were considered. Patients were assessed at baseline and 1, 3, 6, 9, 12, 18, 24 and 36 months postoperatively. During each visit, a clinical assessment was performed to determine the volume difference between both arms and hands (through circumference measurements and water displacement). Clinical BCRL was defined as a ≥5% increase in relative arm volume difference compared to the baseline value. Variables related to (1) the disturbance of lymphatic transport (through lymphofluoroscopy), (2) the demographics and general health of the patient and (3) the breast cancer and treatment of the patient were collected. Results: We included data of 118 patients in the present study. Thirty-eight patients (39.8%) developed BCRL. Early disturbance of lymphatic transport was identified as a risk factor for the development of clinical BCRL (HR 2.808). Breast-cancer- and treatment-related variables such as axillary lymph node dissection (ALND) (HR 15.127), tumor stage (HR 1.745), mastectomy (HR 0.186), number of positive lymph nodes (HR 1.121), number of removed lymph nodes (HR 1.055), radiotherapy of the axilla (HR 2.715), adjuvant taxanes (HR 3.220) and postsurgical complications (HR 2.590) were identified as significant risk factors for the development of BCRL. In the multivariate analysis, age and ALND were withheld as independent risk factors for the development of BCRL. Conclusion: Lymphofluoroscopy can identify an early disturbance of lymphatic transport after breast cancer treatment. Patients with an early disturbance of lymphatic transport are considered to be a high-risk group for the development of BCRL. This study also confirms that age and ALND are predictors for the development of BCRL. Therefore, a surveillance program of these patients with lymphofluoroscopy could be useful to identify lymphedema in subclinical stages.

Prediction of lymphedema occurrence in patients with breast cancer using the optimized combination of ensemble learning algorithm and feature selection

BACKGROUND

Breast cancer-related lymphedema is one of the most important complications that adversely affect patients' quality of life. Lymphedema can be managed if its risk factors are known and can be modified. This study aimed to select an appropriate model to predict the risk of lymphedema and determine the factors affecting lymphedema.

METHOD

This study was conducted on data of 970 breast cancer patients with lymphedema referred to a lymphedema clinic. This study was designed in two phases: developing an appropriate model to predict the risk of lymphedema and identifying the risk factors. The first phase included data preprocessing, optimizing feature selection for each base learner by the Genetic algorithm, optimizing the combined ensemble learning method, and estimating fitness function for evaluating an appropriate model. In the second phase, the influential variables were assessed and introduced based on the average number of variables in the output of the proposed algorithm.

RESULT

Once the sensitivity and accuracy of the algorithms were evaluated and compared, the Support Vector Machine algorithm showed the highest sensitivity and was found to be the superior model for predicting lymphedema. Meanwhile, the combined method had an accuracy coefficient of 91%. The extracted significant features in the proposed model were the number of lymph nodes to the number of removed lymph nodes ratio (68%), feeling of heaviness (67%), limited range of motion in the affected limb (65%), the number of the removed lymph nodes ( 64%), receiving radiotherapy (63%), misalignment of the dominant and the involved limb (62%), presence of fibrotic tissue (62%), type of surgery (62%), tingling sensation (62%), the number of the involved lymph nodes (61%), body mass index (61%), the number of chemotherapy sessions (60%), age (58%), limb injury (53%), chemotherapy regimen (53%), and occupation (50%).

CONCLUSION

Applying a combination of ensemble learning approach with the selected classification algorithms, feature selection, and optimization by Genetic algorithm, Lymphedema can be predicted with appropriate accuracy. Developing applications by effective variables to determine the risk of lymphedema can help lymphedema clinics choose the proper preventive and therapeutic method.

Intraoperative pathologically-calibrated diagnosis of lymph nodes involved by breast cancer cells based on electrical impedance spectroscopy; a prospective diagnostic human model study

BACKGROUND

Nodal status evaluation is a crucial step in determining prognostic factors and managing treatment strategies for breast cancer patients. Preoperative (CNB), intraoperative (SLNB), and even postoperative techniques (Formalin-Fixed Paraffin-Embedded sectioning, FFPE) have definite limitations of precision or sometimes are time-consuming for the result declaration. The primary purpose of this prospective study is to provide a precise complementary system for distinguishing lymph nodes (LNs) involved by cancerous cells in breast cancer patients intraoperatively.

METHODS

The proposed system, Electrical Lymph Scoring(ELS), is designed based on the dielectric properties of the under-test LNs. The system has a needle-shaped 2-electrode probe entered into SLNs or ALNs dissected from patients through standard surgical guidelines. Impedance magnitude in f = 1 kH (Z_1kHz) and Impedance Phase Slope in frequency ranges of 100 kHz-500 kHz (IPS) were then extracted from the impedance spectroscopy data in a cohort study of 77 breast cancer patients(totally 282 dissected LNs) who had been undergone surgery before (n = 55) or after (n = 22) chemical therapies (non-neoadjuvant or neoadjuvant chemotherapy). A new admittance parameter(Y_n^') also proposed for LN detection in neoadjuvant chemotherapy patients.

RESULTS

Considering the permanent pathology result as the gold standard checked by two independent expert pathologists, a significant correlation was observed between the presence of cancerous cells in LNs and individual ranges of the ELS electrical responses. Compared with normal LNs containing fatty ambient and immune cells, LNs involved by cancerous clusters would reduce the Z_1kHz and increase the IPS. These changes correlate with fat metabolism by cancer cells due to their Fatty Acid Oxidation (FAO) in LN, which results in different dielectric properties between high and low-fat content of normal and cancerous LNs, respectively.

CONCLUSIONS

By finding the best correlation between our defined impedimetric parameters and pathological states of tested LNs, a real-time intraoperative detection approach was developed for highly-sensitive (92%, P<0.001) diagnosis of involved sentinel or axillary LNs. The impact of real-time intraoperative scoring of SLNs would make a pre-estimation about the necessity of excising further LNs to help the surgeon for less invasive surgery, especially in the absence of frozen-section equipment.

Primary lymphoedema

Lymphoedema is the swelling of one or several parts of the body owing to lymph accumulation in the extracellular space. It is often chronic, worsens if untreated, predisposes to infections and causes an important reduction in quality of life. Primary lymphoedema (PLE) is thought to result from abnormal development and/or functioning of the lymphatic system, can present in isolation or as part of a syndrome, and can be present at birth or develop later in life. Mutations in numerous genes involved in the initial formation of lymphatic vessels (including valves) as well as in the growth and expansion of the lymphatic system and associated pathways have been identified in syndromic and non-syndromic forms of PLE. Thus, the current hypothesis is that most cases of PLE have a genetic origin, although a causative mutation is identified in only about one-third of affected individuals. Diagnosis relies on clinical presentation, imaging of the structure and functionality of the lymphatics, and in genetic analyses. Management aims at reducing or preventing swelling by compression therapy (with manual drainage, exercise and compressive garments) and, in carefully selected cases, by various surgical techniques. Individuals with PLE often have a reduced quality of life owing to the psychosocial and lifelong management burden associated with their chronic condition. Improved understanding of the underlying genetic origins of PLE will translate into more accurate diagnosis and prognosis and personalized treatment.

Comparison of Shoulder-Arm Complex Pain, Function, and Scapular Dyskinesia in Women With and Without Unilateral Lymphedema After Breast Cancer Surgery

INTRODUCTION

Lymphedema is the most important complication seen after breast cancer surgery. The study aimed to evaluate pain, shoulder-arm complex function, and scapular function in women who developed lymphedema after breast cancer surgery and to compare these with women without lymphedema.

MATERIALS AND METHODS

Fifty women with lymphedema (age, 54.34 ± 9.08 years; body mass index, 30.10 ± 4.03 kg/cm²) and 57 women without lymphedema (age, 53.68 ± 9.41 years; body mass index, 29.0 ± 5.44 kg/cm²) after unilateral surgery for breast cancer were included. Clinical and demographic information was noted. The severity of lymphedema with perimeter measurements (Frustum model), level of heaviness discomfort sensation with a visual analog scale, pain threshold with a digital algometer, shoulder-arm complex functionality with the Disabilities of the Arm, Shoulder, Hand Problems Survey (DASH), and scapular function with observational scapular dyskinesia and lateral scapular sliding tests were assessed. The t test, χ² test, and Mann-Whitney U test were used for analyses.

RESULTS

The follow-up duration after the surgery was 4.24 ± 2.97 years and 3.19 ± 1.76 years, and the upper extremity volume was 2106.65 ± 510.82 cm³ and 1725.92 ± 342.49 cm³ in the lymphedema group and in the no-lymphedema group, respectively. In the lymphedema group, arm-heaviness discomfort, pain threshold levels in the trapezius and deltoid muscles, and DASH scores were worse (P < .05). The rate of scapular dyskinesia (70.0%) and type 2 scapula (32%) in the surgical side was higher in patients with lymphedema.

CONCLUSION

The pain pressure threshold in the trapezius and deltoid muscles, heaviness sensation level, and inadequate upper extremity function are significantly higher in patients with lymphedema, and the scapular dyskinesia rate was higher.

Incidence of lymphedema in the lower limbs and lymphocyst formation within one year of surgery for endometrial cancer: A prospective longitudinal multicenter study

OBJECTIVE

The study aimed to determine the incidence of lower limb lymphedema (LLL) after surgery for endometrial cancer (EC) by means of three methods, and to determine the incidence of lymphocysts after one year.

METHODS

A prospective longitudinal multicenter study was conducted in 14 hospitals in Sweden. Two-hundred-and-thirty-five women with EC were included; 116 underwent surgery that included lymphadenectomy (+LA) and 119 were without lymphadenectomy (-LA). Lymphedema was assessed objectively on four occasions; preoperatively, at 4-6 weeks, six months and one year postoperatively using systematic measurement of leg circumferences, enabling calculation of leg volumes, and a clinical grading of LLL, and subjectively by the patient's perception of lymphedema measured by a lymphedema-specific quality-of-life instrument. Lymphocyst was evaluated by vaginal ultrasonography.

RESULTS

After one year the incidence of LLL after increase in leg volume adjusted for body mass index was 15.8% in +LA women and 3.4% in -LA women. The corresponding figures for clinical grading were 24.1% and 11.8%, and for patient-reported perceived LLL 10.7% and 5.1%. The agreement between the modalities revealed fair to moderate correlation between patient-reported LLL and clinical grading, but poor agreement between volume increase and patient-reported LLL or clinical grading. Lymphocysts were found in 4.3% after one year.

CONCLUSIONS

Although the incidence of LLL and lymphocysts after surgery for EC including LA seemed to be relatively high the study demonstrated significant variations in incidence depending on the measurement modality. This emphasizes the need for a 'gold standard' of measurement of LLL in clinical practice and research.

Tissue Dielectric Constant Measures in Women With and Without Clinical Trunk Lymphedema Following Breast Cancer Surgery: A 78-Week Longitudinal Study

OBJECTIVE

Following breast cancer surgery with lymph node removal, women are at risk of developing lymphedema in the upper extremity or trunk. Currently, trunk lymphedema diagnosis relies on a clinical assessment because no quantifiable standard method exists. Tissue dielectric constant (TDC) values are quantifiable measures of localized skin tissue water and may be able to detect trunk lymphedema. The goal of this study was to (1) compare parameters derived from TDC measurements with those derived from clinically accepted criteria for trunk lymphedema in women following breast cancer surgery and (2) explore the potential utility of TDC to detect trunk lymphedema early in its progression.

METHODS

This prospective longitudinal study, a secondary analysis from a larger study, observed women with and without clinically determined truncal lymphedema following breast cancer surgery. TDC was measured on the lateral trunk wall at post-surgery weeks 2, 4, 12, and 78 in women who had surgical breast cancer treatment with lymph node removal. Clinical assessment for trunk lymphedema was determined at 78 weeks by a lymphedema expert. Comparison of TDC measurements in women with and without clinical trunk lymphedema was analyzed.

RESULTS

Clinical assessment identified trunk lymphedema in 15 out of 32 women at 78 weeks. These women had TDC ratios statistically higher than women without truncal lymphedema.

CONCLUSION

The overall findings indicate that TDC has the ability to quantify trunk lymphedema and might be valuable in early detection.

IMPACT

TDC may be a beneficial tool in the early detection of breast cancer-related trunk lymphedema, which could trigger intervention.

LAY SUMMARY

A new device may help recognize trunk lymphedema in patients with breast cancer so they could receive appropriate treatment.

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

Background:

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

Methods:

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

Results:

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

Conclusion:

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

Psychometric evaluation of the Persian version of the Lymphedema Life Impact Scale (LLIS, version 1) in breast cancer patients

Background

Despite the high prevalence of lymphedema in Iranian breast cancer patients, there is no valid instrument for measuring quality of life in this population. The aim of this study was to assess reliability and validity of the Persian version of Lymphedema Life Impact Scale (LLIS) in breast cancer patients.

Methods

Forward-backward procedure was applied to translate The LLIS from English into Persian. The LLIS is an 18-item measure of physical, psychosocial, and functional impairments caused by lymphedema. Experts and patients assessed content and face validity, respectively. Discriminant validity was evaluated by comparing breast cancer patients with and without lymphedema. Convergent validity was assessed by comparing LLIS score with SF-36 (functional component) and the EORTC-QLQ-C30 (functional component). The construct validity also was evaluated using confirmatory and exploratory factor analyses. Internal consistency was evaluated by Cronbach’s alpha coefficient. Stability was assessed by test-retest analysis over a one-week interval in 13 patients.

Results

In all 446 breast cancer patients were entered into the study. The content and face validity of Persian version of LLIS were acceptable and minor corrections were applied in final version. The questionnaire differentiated well in patients’ with and without lymphedema and not lending support to its discriminant validity. Confirmatory factor analysis showed a good fit for the data. Cronbach’s alpha coefficient in physical, psychosocial and functional subscales were 0.873, 0.854 and 0.884 respectively. Intra-class correlation coefficient of total score of the LLIS was 0.96.

Conclusions

The findings of this study suggest a first indication that reliability and validity of the Persian version of LLIS in patients with breast cancer induced lymphedema was good. Application of this instrument for identifying problems of patients with upper extremity lymphedema may be helpful in designing interventions to improve quality of life.

Long term effects of manual lymphatic drainage and active exercises on physical morbidities, lymphoscintigraphy parameters and lymphedema formation in patients operated due to breast cancer: A clinical trial

PURPOSE

evaluate whether manual lymphatic drainage (MLD) or active exercise (AE) is associated with shoulder range of motion (ROM), wound complication and changes in the lymphatic parameters after breast cancer (BC) surgery and whether these parameters have an association with lymphedema formation in the long run.

METHODS

Clinical trial with 106 women undergoing radical BC surgery, in the Women's Integrated Healthcare Center-University of Campinas. Women were matched for staging, age and body mass index and were allocated to performed AE or MLD, 2 weekly sessions during one month after surgery. The wound was evaluated 2 months after surgery. ROM, upper limb circumference measurement and upper limb lymphoscintigraphy were performed before surgery, and 2 and 30 months after surgery.

RESULTS

The incidence of seroma, dehiscence and infection did not differ between groups. Both groups showed ROM deficit of flexion and abduction in the second month postoperative and partial recovery after 30 months. Cumulative incidence of lymphedema was 23.8% and did not differ between groups (p = 0.29). Concerning the lymphoscintigraphy parameters, there was a significant convergent trend between baseline degree uptake (p = 0.003) and velocity visualization of axillary lymph nodes (p = 0.001) with lymphedema formation. A reduced marker uptake before or after surgery predicted lymphedema formation in the long run (>2 years). None of the lymphoscintigraphy parameters were shown to be associated with the study group. Age ≤39 years was the factor with the greatest association with lymphedema (p = 0.009). In women with age ≤39 years, BMI >24Kg/m2 was significantly associated with lymphedema (p = 0.017). In women over 39 years old, women treated with MLD were at a significantly higher risk of developing lymphedema (p = 0.011).

CONCLUSION

Lymphatic abnormalities precede lymphedema formation in BC patients. In younger women, obesity seems to be the major player in lymphedema development and, in older women, improving muscle strength through AE can prevent lymphedema. In essence, MLD is as safe and effective as AE in rehabilitation after breast cancer surgery.

Evolutionary aspects of non-metastatic breast cancer after primary treatment in a sub-Saharan African setting: a 16-year retrospective review at the Douala general hospital, Cameroon

BACKGROUND

Breast cancer has a high case fatality rate in sub-Saharan Africa, and this is chiefly because of late detection and inadequate treatment resources. Progressive renovations in diagnostic and management modalities of non-metastatic breast cancer (NMBC) have been noted in the region but there is paucity of data describing the clinical progress of patients with NMBC. This study sought to determine the rates of local relapse, distant metastasis and sequelae and the time span from initial treatment to the occurrence of these adverse events among patients with NMBC.

METHODS

This was a retrospective review of medical records of patients with histologically confirmed NMBC at the department of radiation therapy and oncology of the Douala General Hospital in Cameroon from the January 1997 to December 2012 period. Clinicopathological and treatment characteristics as well as occurrences of adverse events were studied.

RESULTS

A total of 260 cases were reviewed of which 224/260 (86.2%) had invasive ductal carcinoma. Surgery was performed on 258/260 cases (99.2%) with 187/258 (72.5%) being modified radical mastectomies. Various treatment combinations were used in up to 228/260 patients (87.5%) while surgery alone was the treatment in the remaining 32 cases (12.5%). Metastasis occurred in 142/260 cases (54.6%) of which 68/142 (26.2%) were local relapses and 74/142 (28.5%) were distant metastases. Among the cases of distant metastasis, 9.2% were bone, 8.5% lungs, 6.9% nodal, and 5.4% brain. Metastasis to multiple organs was noted in 4.7% of these cases. The median periods of occurrence of local relapse and distant metastases were 13 and 12 months respectively. Sequelae occurred in 26/260 cases (10%) and were noted after an average of 30 months. The main sequelae were lymphoedema (6.5%) and lung fibrosis (1.5%). At the end of the period under review, 118/260 patients (45.4%) were alive and disease-free with a median follow up time of 24 months.

CONCLUSIONS

Adverse events were frequent among patients who received primary treatment for NMBC. Available cancer therapeutic modalities ought to be supplemented with efficient strategies of follow-up and monitoring so as to optimize the care provided to these patients and improve on their survival.

Arm lymphoscintigraphy after axillary lymph node dissection or sentinel lymph node biopsy in breast cancer

PURPOSE

Compare the lymphatic flow in the arm after breast cancer surgery and axillary lymph node dissection (ALND) versus sentinel lymph node biopsy (SLNB) using lymphos-cintigraphy (LS).

PATIENTS AND METHODS

A cross-sectional study with 39 women >18 years who underwent surgical treatment for unilateral breast cancer and manipulation of the axillary lymph node chain through either ALND or SLNB, with subsequent comparison of the lymphatic flow of the arm by LS. The variables analyzed were the area reached by the lymphatic flow in the upper limb and the sites and number of lymph nodes identified in the ALND or SLNB groups visualized in the three phases of LS acquisition (immediate dynamic and static images, delayed scan images). For all analyses, the level of significance was set at 5%.

RESULTS

There was a significant difference between the ALND and SLNB groups, with predominant visualization of lymphatic flow and/or lymph nodes in the arm and axilla (P=0.01) and extra-axillary lymph nodes (P<0.01) in the ALND group. There was no significant difference in the total number of lymph nodes identified between the two groups. However, there was a significant difference in the distribution of lymph nodes in these groups. The cubital lymph node was more often visualized in the immediate dynamic images in the ALND group (P=0.004), while the axillary lymph nodes were more often identified in the delayed scan images of the SLNB group (P<0.01). The deltopectoral lymph node was only identified in the ALND group, but with no significant difference.

CONCLUSION

The lymphatic flow from the axilla was redirected to alternative extra-axillary routes in the ALND group.

Relationship of the number and size of superficial groin lymph nodes with the stage of secondary lymphatic edema

PURPOSE

This study evaluated the relationships of the size and number of superficial groin lymph nodes with the lower limb lymphedema stage and thus examined the role of superficial lymphatic lymph nodes in secondary lymphedema development.

METHODS

We determined the number and size of superficial groin lymph nodes using horizontal plane computed tomography (CT) and the lymphedema stage in the lower limbs of 25 patients with gynecologic cancer.

RESULTS

The patients had an average of 2.92 (range, 1-7) superficial groin lymph nodes; the mean size of the 146 evaluated lymph nodes was 7.55 mm (range, 5-15 mm). In 19 of 25 patients (76%), the side with major edema contained fewer superficial groin lymph nodes. In total, 22 patients (88%) had fewer superficial groin lymph nodes or a smaller total lymph node size on the edematous dominant side.

CONCLUSIONS

In this evaluation of the link between superficial groin lymph node laterality and secondary lymphedema staging, we found that patients with large lymph node numbers and sizes tended to present with a relatively earlier stage of lymphedema. Our results therefore suggest that the size and number of superficial groin lymph nodes affect the lymphedema stage. J. Surg. Oncol. 2016;114:940-946. © 2016 Wiley Periodicals, Inc.

Assessment of Risk Factors in Patients who presented to the Outpatient Clinic for Breast Cancer-Related Lymphedema

OBJECTIVE

Lymphedema is one of the most debilitating outcomes of breast cancer treatment. We aimed to compare the demographic and clinical characteristics of breast cancer patients with and without lymphedema, to assess risk factors for lymphedema, and to evaluate treatment outcomes in lymphedema patients.

MATERIALS AND METHODS

Demographic and clinical characteristics of 84 women with previous surgery for breast cancer who presented to the outpatient clinic between March 2014 and May 2015 were retrospectively extracted from patient records.

RESULTS

Upper extremity lymphedema was detected in 34 of 84 patients (40.5%). The mean age, body mass index, the number of positive lymph nodes and the number of patients with postoperative radiotherapy were significantly higher among patients with lymphedema than those without (p<0.05). Educational level of patients with lymphedema was significantly lower than the other group (p<0.05). The correlation analysis revealed an association between age, educational level, body mass index, tumor stage, number of positive lymph nodes, postoperative radiotherapy and presence of lymphedema. Postoperative radiotherapy was detected as the only independent risk factor by logistic regression analysis. Fourteen out of 26 lymphedema patients were assigned to education, skin care, exercise and compression bandaging therapy. Upper extremity volumes and volume differences were significantly improved after treatment.

CONCLUSION

Advanced age, low educational level, obesity, tumor size, the number of positive lymph nodes and postoperative radiotherapy correlated with the development of lymphedema. Within these factors, postoperative radiotherapy was detected as an independent risk factor for the development of lymphedema. Patient education, skin care, exercise and compression bandage therapy are effective treatment options in breast cancer-related lymphedema.

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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