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Shen A, Li X, Zhao H, Ye J, Zhao H, Zhou Y, Wang Y, Zhang Z, Bian J, Zhang L, Wu P, Qiang W, Lu Q. Preoperative inter-arm differences and normative-based thresholds for lymphedema in Chinese breast cancer patients: Insights from a large cohort study. Asia Pac J Oncol Nurs 2024; 11:100567. [PMID: 39286531 PMCID: PMC11403264 DOI: 10.1016/j.apjon.2024.100567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Accepted: 07/31/2024] [Indexed: 09/19/2024] Open
Abstract
Objective Early detection and diagnosis of lymphedema are crucial for effective treatment and prevention of its progression. Normative-based diagnostic thresholds can enhance diagnostic accuracy in the absence of preoperative measurements. This study aimed to investigate preoperative inter-arm differences and the associated factors, as well as to determine normative-based thresholds for lymphedema in Chinese breast cancer patients. Methods This study utilized baseline data from a large cohort of Chinese breast cancer patients. Bilateral arm circumferences were measured at the wrist and at 10 cm intervals proximally up to 40 cm. Arm volumes were calculated using the truncated cone formula. Paired t test, repeated measures analysis of variance, and regression analysis were performed. Results A total of 1707 breast cancer patients were included. Paired t tests showed that the dominant arm circumferences and volumes were significantly larger than those of the nondominant arm (P < 0.001). Regression analysis and repeated measures analysis of variance revealed that hand dominance was the influencing factor of inter-arm differences (P < 0.05). Normative-based thresholds determined by two standard deviations above the mean inter-arm volume ratio were 1.057 for the dominant arm and 1.079 for the nondominant arm. Conclusions The absolute and relative normative-based thresholds for Chinese breast cancer patients differed slightly from the commonly used diagnostic criteria and those reported in Western populations and among Chinese healthy women. The normal variability and asymmetry associated with arm dominance underscore the importance of preoperative baseline assessments. Implementing normative-based diagnostic thresholds can facilitate more accurate lymphedema diagnosis when preoperative measurements are unavailable. Trial registration Registration No. ChiCTR2200057083.
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Affiliation(s)
- Aomei Shen
- Department of Nursing, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center for Cancer, Tianjin's Clinical Research Center for Cancer, Key Laboratory of Breast Cancer Prevention and Therapy, Tianjin Medical University Ministry of Education, Tianjin, China
- School of Nursing, Peking University, Beijing, China
| | - Xin Li
- Department of Nursing, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center for Cancer, Tianjin's Clinical Research Center for Cancer, Key Laboratory of Breast Cancer Prevention and Therapy, Tianjin Medical University Ministry of Education, Tianjin, China
- School of Nursing, Tianjin Medical University, Tianjin, China
| | - Hongmei Zhao
- Department of General Surgery, Peking University Third Hospital, Beijing, China
| | - Jingming Ye
- Department of Thyroid and Breast Surgery, Peking University First Hospital, Beijing, China
| | - Hongmeng Zhao
- The First Department of Breast Surgery, Tianjin Medical University Cancer Institute & Hospital, Tianjin, China
| | - Yujie Zhou
- Department of Nursing, Peking University Third Hospital, Beijing, China
| | - Yue Wang
- Department of Thyroid and Breast Surgery, Peking University First Hospital, Beijing, China
| | - Zhongning Zhang
- Department of Nursing, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center for Cancer, Tianjin's Clinical Research Center for Cancer, Key Laboratory of Breast Cancer Prevention and Therapy, Tianjin Medical University Ministry of Education, Tianjin, China
- School of Nursing, Tianjin Medical University, Tianjin, China
| | - Jingru Bian
- Department of Nursing, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center for Cancer, Tianjin's Clinical Research Center for Cancer, Key Laboratory of Breast Cancer Prevention and Therapy, Tianjin Medical University Ministry of Education, Tianjin, China
- School of Nursing, Tianjin Medical University, Tianjin, China
| | - Liyuan Zhang
- Department of Nursing, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center for Cancer, Tianjin's Clinical Research Center for Cancer, Key Laboratory of Breast Cancer Prevention and Therapy, Tianjin Medical University Ministry of Education, Tianjin, China
- School of Nursing, Tianjin Medical University, Tianjin, China
| | - Peipei Wu
- Department of Nursing, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center for Cancer, Tianjin's Clinical Research Center for Cancer, Key Laboratory of Breast Cancer Prevention and Therapy, Tianjin Medical University Ministry of Education, Tianjin, China
- Lymphedema Clinic, Tianjin Medical University Cancer Institute & Hospital, Tianjin, China
| | - Wanmin Qiang
- Department of Nursing, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center for Cancer, Tianjin's Clinical Research Center for Cancer, Key Laboratory of Breast Cancer Prevention and Therapy, Tianjin Medical University Ministry of Education, Tianjin, China
| | - Qian Lu
- School of Nursing, Peking University, Beijing, China
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Bhimani F, Feldman S, Cavalli A, Chen Y, Obaid L, Rachofsky C, Gupta A, Pastoriza J, Johnson K, McEvoy M. Axillary Reverse Mapping Aids in Reducing the Rates of Breast Cancer-Related Lymphedema in Underserved Ethnically Diverse Population. Ann Surg Oncol 2024; 31:5937-5946. [PMID: 38844631 DOI: 10.1245/s10434-024-15577-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 05/22/2024] [Indexed: 08/09/2024]
Abstract
BACKGROUND Breast cancer-related lymphedema (BCRL) poses a significant risk following sentinel lymph node biopsy (SLNB) and axillary lymph node dissection (ALND), particularly affecting ethnic minorities, with a twofold increased risk. Axillary reverse mapping (ARM), a novel technique, shows potential in reducing BCRL rates, yet its utility in ethnic minorities lacks sufficient exploration. Therefore, our study aims to investigate the utility and outcomes of ARM on BCRL in an ethnic diverse group. METHODS A retrospective chart review of ARM patients from January 2019 to July 2022 was conducted, monitoring patients over 24 months at 3-month intervals using SOZO® scores, with comparisons with preoperative baselines. RESULTS Of the 212 patients, 83% belonged to ethnic minorities. SLNB was performed in 83%, ALND in 17%, and 62.3% underwent radiation therapy. Positive lymph nodes were found in 31.6%, with 22.2% exhibiting blue nodes and 25.9% exhibiting blue lymphatics. Of identified blue nodes, 70.2% were excised, including 51.5% crossover nodes. Lymphedema occurred in 3 patients, resulting in a BCRL rate of 1.4%. Compared with an historical BCRL incidence of 40.4% following ALND in ethnic minorities, our study reported a significantly lower rate of 8% (p < 0.001). CONCLUSION The ARM procedure can significantly lower BCRL in ethnic minority groups. The combination of ARM and bioimpedance spectroscopy led to a remarkably low BCRL rate of 1.4%. Notably, none of the patients in our study developed an axillary recurrence at 24-month follow-up. Nevertheless, future studies with larger sample sizes are warranted to better understand the utility of the ARM technique in this population.
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Affiliation(s)
- Fardeen Bhimani
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Comprehensive Cancer Care, Bronx, NY, USA
| | - Sheldon Feldman
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Comprehensive Cancer Care, Bronx, NY, USA
- Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Yu Chen
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Comprehensive Cancer Care, Bronx, NY, USA
| | - Liane Obaid
- Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Anjuli Gupta
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Comprehensive Cancer Care, Bronx, NY, USA
- Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jessica Pastoriza
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Comprehensive Cancer Care, Bronx, NY, USA
- Albert Einstein College of Medicine, Bronx, NY, USA
| | - Kelly Johnson
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Comprehensive Cancer Care, Bronx, NY, USA
| | - Maureen McEvoy
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Comprehensive Cancer Care, Bronx, NY, USA.
- Albert Einstein College of Medicine, Bronx, NY, USA.
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3
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Cogliandro A, Mirra C, Gratteri M, Mannella V, Salzillo R, Bressi F, Miccinilli S, De Bernardis R, Savani L, Marangi GF, Persichetti P. LYMPH-Q translation, cultural adaptation and validation in Italian language: A prospective PROMs-based study on breast cancer-related arm lymphedema for patients' education. J Plast Reconstr Aesthet Surg 2024; 96:199-206. [PMID: 39096736 DOI: 10.1016/j.bjps.2024.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Revised: 06/18/2024] [Accepted: 07/08/2024] [Indexed: 08/05/2024]
Abstract
BACKGROUND Upper Extremity Lymphedema following oncological breast surgery affects not only the patient's physique, but also the patient's psychological sphere. One of the best known PROMs-based questionnaires for investigating the condition is the LYMPH-Q. The study aimed to perform the Italian translation and cultural adaptation of the LYMPH-Q and to assess if, independently from disease evolution, arm sleeve improves QoL in these patients. MATERIALS AND METHODS Translation included 4 steps: Forward translation, Back translation, Back translation review and Patient interviews. The questionnaire was administered to 50 female patients older than 18 years of age with UEL who received a prescription for daily use of a compression sheath. A second administration took place 30 days after. Forty-four patients completed the study (Group 1: 26 patients with indication to use compression sleeve who wore it; Group 2:18 patients who despite the prescription did not want to wear it. A descriptive statistical analysis was performed with Prism 9 software. RESULTS T-tests showed statistical significance for changes in "Symptoms," "Function," "Appearance" and "Psychological" scales. There were no statistically significant changes for "Information scale" in Group 1 and for all scales in Group 2. CONCLUSION Data from this observational study show that HR-QOL analyzed from the patients' perspective also tends to improve in terms of symptoms, function, appearance, and psychological sphere in patients with BCRL when using a compression sheath. The Lymph-Q has proven to be a valuable ally of the physician attempting to improve treatment approaches for BCRL based not only on scientific evidence but also on PROMs.
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Affiliation(s)
- Annalisa Cogliandro
- Department of Plastic, Reconstructive and Cosmetic Surgery, Rome Biomedical Campus Foundation, Via Alvaro del Portillo 200, Rome, Italy
| | - Carlo Mirra
- Department of Plastic, Reconstructive and Cosmetic Surgery, Rome Biomedical Campus Foundation, Via Alvaro del Portillo 200, Rome, Italy
| | - Marco Gratteri
- Department of Plastic, Reconstructive and Cosmetic Surgery, Rome Biomedical Campus Foundation, Via Alvaro del Portillo 200, Rome, Italy.
| | | | - Rosa Salzillo
- Department of Plastic, Reconstructive and Cosmetic Surgery, Rome Biomedical Campus Foundation, Via Alvaro del Portillo 200, Rome, Italy
| | - Federica Bressi
- Physical and Rehabilitative Medicine Department, Rome Biomedical Campus Foundation, Via Alvaro del Portillo 200, Rome, Italy
| | - Sandra Miccinilli
- Physical and Rehabilitative Medicine Department, Rome Biomedical Campus Foundation, Via Alvaro del Portillo 200, Rome, Italy
| | - Riccardo De Bernardis
- Department of Plastic, Reconstructive and Cosmetic Surgery, Rome Biomedical Campus Foundation, Via Alvaro del Portillo 200, Rome, Italy
| | - Luca Savani
- Department of Plastic, Reconstructive and Cosmetic Surgery, Rome Biomedical Campus Foundation, Via Alvaro del Portillo 200, Rome, Italy
| | - Giovanni Francesco Marangi
- Department of Plastic, Reconstructive and Cosmetic Surgery, Rome Biomedical Campus Foundation, Via Alvaro del Portillo 200, Rome, Italy
| | - Paolo Persichetti
- Department of Plastic, Reconstructive and Cosmetic Surgery, Rome Biomedical Campus Foundation, Via Alvaro del Portillo 200, Rome, Italy
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Aguilera-Eguía RA, Roco Videla Á, López Soto OP, Fuentes-Barría H, Yáñez-Baeza C, Melo Lonconao M. [Beyond pulmonary function: the impact of obesity on breast cancer-related lymphedema]. NUTR HOSP 2024; 41:928-929. [PMID: 38967299 DOI: 10.20960/nh.05328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2024] Open
Abstract
Introduction
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Affiliation(s)
| | - Ángel Roco Videla
- Facultad de Ciencias de la Salud. Programa de Magíster en Ciencias Químico-Biológicas. Universidad Bernardo O´Higgins
| | | | | | - Cristian Yáñez-Baeza
- Departamento de Ciencias Clínicas y Preclínicas. Facultad de Medicina. Universidad Católica de la Santísima Concepción
| | - Mariana Melo Lonconao
- Departamento de Salud Pública. Facultad de Medicina. Universidad Católica de la Santísima Concepción
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5
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Tuğral A, Akyol M, Çolakoğlu Ö, Bakar Y. Risk Profiling of Breast Cancer-Related Lymphedema (BCRL) in Patients With Breast Cancer Via Using Body Composition and Tissue Dielectric Constant (TDC) Method: A Cross-Sectional Study. Clin Breast Cancer 2024:S1526-8209(24)00218-0. [PMID: 39214845 DOI: 10.1016/j.clbc.2024.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 07/31/2024] [Accepted: 08/04/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Breast Cancer-Related Lymphedema (BCRL) is one of the most prominent long-term side effects of breast cancer (BC) treatment. Although an increased BMI is a well-recognized risk factor for BCRL, there is a lack of knowledge regarding the potential associations between body composition and the risk of BCRL. Therefore, this study aimed to analyze the BCRL risk profiles of surgically operated BC patients via body composition and the Tissue Dielectric Constant (TDC) method, respectively. METHODS A total of 72 patients were included. Patients' risk for BCRL was assessed with Moisture MeterD (Delfin, Finland) in 4 different probes each has unique penetration depths from 0.5 (10 mm) to 5.0 (55 mm) at both upper extremities. The body composition was analyzed with Tanita-BC-420 (TANITA, Japan). Comparing the dielectric values of extremities and proportioning to one another as TDC ratio (at-risk side/unaffected side) was used to profile BCRL risk. RESULTS TDC values of the thorax reference point were significantly higher in all four probes on the at-risk side (P < .05). TDC ratios in the forearm and Thorax points were significantly correlated with fat mass (r = 0.256, P = .030; r = 0.269, P = .022) as well as with visceral fat rating (VFR) (r = 0.340, P = .003; r = 0.466, P < .001). CONCLUSION This study highlights the need for further care and investigation in the assessment and prediction of BCRL by considering body composition. Since the risk reduction of BCRL can be maximized by considering the individual features, we can conclude that patients with higher body fat irrespective of the BMI should be followed up regularly.
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Affiliation(s)
- Alper Tuğral
- Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Izmir Bakırçay University, Izmir, Turkey.
| | - Murat Akyol
- Faculty of Medicine, Department of Medical Oncology, Izmir Bakırçay University, Izmir, Turkey
| | - Öykü Çolakoğlu
- Department of Medical Oncology, Nutrition Department, Izmir Bakırçay University Çiğli State and Training Hospital, Izmir, Turkey
| | - Yeşim Bakar
- Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Izmir Bakırçay University, Izmir, Turkey
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Bhimani F, McEvoy M, Chen Y, Gupta A, Pastoriza J, Cavalli A, Obaid L, Rachofsky C, Fruchter S, Feldman S. Comprehensive strategies in breast cancer-related lymphedema prevention: insights from a multifaceted program. Front Oncol 2024; 14:1418610. [PMID: 39081716 PMCID: PMC11286467 DOI: 10.3389/fonc.2024.1418610] [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: 04/16/2024] [Accepted: 06/24/2024] [Indexed: 08/02/2024] Open
Abstract
Background Breast cancer-related lymphedema (BCRL) profoundly impacts patients' quality of life, causing heightened depression, anxiety, and physical limitations. Surgical removal of the axillary nodes, combined with radiation therapy, is a significant risk factor for BCRL. Smarter axillary surgery, coupled with early detection and fostering lymphedema education, significantly improves BCRL management, promoting timely diagnosis and treatment. A lymphedema prevention program encompassing all these factors can significantly aid in preventing, treating, and reducing the severity of BCRL cases. Therefore, our study aims to share our insights and experiences gained from implementing a lymphedema prevention program at our institution. Methods & Results At our institution, axillary reverse mapping (ARM) is performed on all patients undergoing axillary surgery. We surveil these patients with pre- and postoperative SOZO® measurements using bioimpedance spectroscopy to detect sub-clinical lymphedema. Concerning education, we use a 3-pronged approach with surgeons, nurse practitioners, and video representation for patients. We have had 212 patients undergo the ARM procedure since 2019, with three (1.41%) developing persistent lymphedema. Conclusion Our study underscores the significance of a comprehensive lymphedema prevention program, integrating smarter axillary surgery, early detection, and patient education. The lymphedema rate of 1.41% not only validates the success rate of these interventions but also advocates for their widespread adoption to enhance the holistic care of breast cancer survivors. As we continue to refine and expand our program, further research, and long-term follow-up are crucial to improve prevention strategies continually and enhance the overall well-being of individuals at risk of BCRL.
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Affiliation(s)
- Fardeen Bhimani
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Comprehensive Cancer Center, Bronx, NY, United States
| | - Maureen McEvoy
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Comprehensive Cancer Center, Bronx, NY, United States
| | - Yu Chen
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Comprehensive Cancer Center, Bronx, NY, United States
| | - Anjuli Gupta
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Comprehensive Cancer Center, Bronx, NY, United States
| | - Jessica Pastoriza
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Comprehensive Cancer Center, Bronx, NY, United States
| | - Arianna Cavalli
- Albert Einstein College of Medicine, Bronx, NY, United States
| | - Liane Obaid
- Albert Einstein College of Medicine, Bronx, NY, United States
| | | | - Shani Fruchter
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Comprehensive Cancer Center, Bronx, NY, United States
| | - Sheldon Feldman
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Comprehensive Cancer Center, Bronx, NY, United States
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7
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Jiang Q, Hu H, Liao J, Li ZH, Tan J. Development and validation of a nomogram for breast cancer-related lymphedema. Sci Rep 2024; 14:15602. [PMID: 38971880 PMCID: PMC11227568 DOI: 10.1038/s41598-024-66573-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Accepted: 07/02/2024] [Indexed: 07/08/2024] Open
Abstract
To establish and validate a predictive model for breast cancer-related lymphedema (BCRL) among Chinese patients to facilitate individualized risk assessment. We retrospectively analyzed data from breast cancer patients treated at a major single-center breast hospital in China. From 2020 to 2022, we identified risk factors for BCRL through logistic regression and developed and validated a nomogram using R software (version 4.1.2). Model validation was achieved through the application of receiver operating characteristic curve (ROC), a calibration plot, and decision curve analysis (DCA), with further evaluated by internal validation. Among 1485 patients analyzed, 360 developed lymphedema (24.2%). The nomogram incorporated body mass index, operative time, lymph node count, axillary dissection level, surgical site infection, and radiotherapy as predictors. The AUCs for training (N = 1038) and validation (N = 447) cohorts were 0.779 and 0.724, respectively, indicating good discriminative ability. Calibration and decision curve analysis confirmed the model's clinical utility. Our nomogram provides an accurate tool for predicting BCRL risk, with potential to enhance personalized management in breast cancer survivors. Further prospective validation across multiple centers is warranted.
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Affiliation(s)
- Qihua Jiang
- Department of Breast Surgery, Third Hospital of Nanchang, No. 2, Xiangshan South Road, Xi Hu District, Nanchang City, 330008, Jiangxi Province, China
| | - Hai Hu
- Department of General Surgery, Third Hospital of Nanchang, No. 2, Xiangshan South Road, Xi Hu District, Nanchang City, 330008, Jiangxi Province, China
| | - Jing Liao
- Department of Breast Surgery, Third Hospital of Nanchang, No. 2, Xiangshan South Road, Xi Hu District, Nanchang City, 330008, Jiangxi Province, China
| | - Zhi-Hua Li
- Department of Breast Surgery, Third Hospital of Nanchang, No. 2, Xiangshan South Road, Xi Hu District, Nanchang City, 330008, Jiangxi Province, China.
- Jiangxi Province Key Laboratory of Breast Diseases, Third Hospital of Nanchang, No. 2, Xiangshan South Road, Xihu District, Nanchang City, 330008, Jiangxi Province, China.
| | - Juntao Tan
- Department of Breast Surgery, Third Hospital of Nanchang, No. 2, Xiangshan South Road, Xi Hu District, Nanchang City, 330008, Jiangxi Province, China.
- Jiangxi Province Key Laboratory of Breast Diseases, Third Hospital of Nanchang, No. 2, Xiangshan South Road, Xihu District, Nanchang City, 330008, Jiangxi Province, China.
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8
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Valente S, Roesch E. Breast cancer survivorship. J Surg Oncol 2024; 130:8-15. [PMID: 38534002 DOI: 10.1002/jso.27627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 03/11/2024] [Indexed: 03/28/2024]
Abstract
Breast cancer survivorship care transitions from active treatment to focus on surveillance and health maintenance. This review article discusses the crucial aspects of breast cancer survivorship, which include cancer surveillance, management of treatment side effects, implementation of a healthy lifestyle, and psychosocial support.
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Affiliation(s)
| | - Erin Roesch
- Hematology/Medical Oncology, Cleveland Clinic, Cleveland, Ohio, USA
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Varghese J, Patani N, Wazir U, Novintan S, Michell MJ, Malhotra A, Mokbel K, Mokbel K. Wire-Free Targeted Axillary Dissection: A Pooled Analysis of 1300+ Cases Post-Neoadjuvant Systemic Therapy in Node-Positive Early Breast Cancer. Cancers (Basel) 2024; 16:2172. [PMID: 38927878 PMCID: PMC11201777 DOI: 10.3390/cancers16122172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Revised: 06/03/2024] [Accepted: 06/04/2024] [Indexed: 06/28/2024] Open
Abstract
Recent advances in neoadjuvant systemic therapy (NST) have significantly improved pathologic complete response rates in early breast cancer, challenging the role of axillary lymph node dissection in nose-positive patients. Targeted axillary dissection (TAD) integrates marked lymph node biopsy (MLNB) and tracer-guided sentinel lymph node biopsy (SLNB). The introduction of new wire-free localisation markers (LMs) has streamlined TAD and increased its adoption. The primary endpoints include the successful localisation and retrieval rates of LMs. The secondary endpoints include the pathological complete response (pCR), SLNB, and MLNB concordance, as well as false-negative rates. Seventeen studies encompassing 1358 TAD procedures in 1355 met the inclusion criteria. The localisation and retrieval rate of LMs were 97% and 99%. A concordance rate of 67% (95% CI: 64-70) between SLNB and MLNB was demonstrated. Notably, 49 days (range: 0-272) was the average LM deployment time to surgery. pCR was observed in 46% (95% CI: 43-49) of cases, with no significant procedure-related complications. Omitting MLNB or SLNB would have under-staged the axilla in 15.2% or 5.4% (p = 0.0001) of cases, respectively. MLNB inclusion in axillary staging post-NST for initially node-positive patients is crucial. The radiation-free Savi Scout, with its minimal MRI artefacts, is the preferred technology for TAD.
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Affiliation(s)
- Jajini Varghese
- The London Breast Institute, The Women’s Health Centre, HCA Healthcare UK, London W1U 9QP, UK
- Royal Free London NHS Trust, Pond Street, London NW3 2QG, UK
- Division of Surgery and Interventional Sciences, University College London, London WC1E 6BT, UK
| | - Neill Patani
- The London Breast Institute, The Women’s Health Centre, HCA Healthcare UK, London W1U 9QP, UK
- Division of Surgery and Interventional Sciences, University College London, London WC1E 6BT, UK
| | - Umar Wazir
- The London Breast Institute, The Women’s Health Centre, HCA Healthcare UK, London W1U 9QP, UK
| | - Shonnelly Novintan
- The London Breast Institute, The Women’s Health Centre, HCA Healthcare UK, London W1U 9QP, UK
- East Suffolk North Essex NHS Foundation Trust, Turner Road, Colchester CO4 5JL, UK
| | - Michael J. Michell
- The London Breast Institute, The Women’s Health Centre, HCA Healthcare UK, London W1U 9QP, UK
- Kings College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK
| | - Anmol Malhotra
- The London Breast Institute, The Women’s Health Centre, HCA Healthcare UK, London W1U 9QP, UK
- Royal Free London NHS Trust, Pond Street, London NW3 2QG, UK
- Division of Surgery and Interventional Sciences, University College London, London WC1E 6BT, UK
| | - Kinan Mokbel
- The London Breast Institute, The Women’s Health Centre, HCA Healthcare UK, London W1U 9QP, UK
- Health and Care Profession Department, Faculty of Health and Life Sciences, University of Exeter Medical School, Exeter EX1 2HZ, UK
| | - Kefah Mokbel
- The London Breast Institute, The Women’s Health Centre, HCA Healthcare UK, London W1U 9QP, UK
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10
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Ogiya A, Kimura K, Ueno T, Iwase T, Ohno S. Time trend of breast cancer-related lymphedema according to body mass index. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108350. [PMID: 38653160 DOI: 10.1016/j.ejso.2024.108350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 03/01/2024] [Accepted: 04/15/2024] [Indexed: 04/25/2024]
Abstract
PURPOSE To clarify how body mass index (BMI) affects the development and temporal trend of breast cancer-related lymphedema (BCRL). METHODS This is a prospective study in which patients with operable breast cancer were registered in a single institute between November 2009 and July 2010. The incidence of lymphedema at 1, 3, and 5 years after surgery was assessed according to BMI, and the trend of newly developed BCRL was examined. Obesity was defined as BMI ≥25 in accordance with the Japan Society for the Study of Obesity. RESULTS A total of 368 patients were included in this study. The multivariate analysis of the whole population showed that high BMI, axillary dissection, and radiotherapy remained as risk factors for BCRL. Patients with high BMI showed a significantly higher incidence of new lymphedema than those with low BMI at 1 year (p < 00.001) regardless of axillary procedures (39.1 % vs 16.3 % for axillary dissection; 15.6 % vs 1.5 % for sentinel lymph node biopsy) but not at 3 and 5 years. Once BCRL developed, patients with high BMI showed slow recovery and 50.0 % of the patients retained edema at 5 years while patients with low BMI showed rapid recovery and 26.7 % retained after 3 years (p = 0.04). CONCLUSION The preoperative BMI affected the incidence and temporal trend of BCRL regardless of axillary procedures or radiotherapy. Patients with high BMI should be given appropriate information about BCRL before surgery with careful follow-up for BCRL after treatment.
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Affiliation(s)
- Akiko Ogiya
- Department of Breast Surgical Oncology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, 1358550, Japan.
| | | | - Takayuki Ueno
- Department of Breast Surgical Oncology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, 1358550, Japan.
| | - Takuji Iwase
- Department of Breast Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital, Aichi, 4538511, Japan
| | - Shinji Ohno
- Breast Oncology Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, 1358550, Japan
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11
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Heller DR, Axelrod B, Sevilimedu V, Morrow M, Mehrara BJ, Barrio AV. Quality of Life After Axillary Lymph Node Dissection Among Racial and Ethnic Minority Women. JAMA Surg 2024; 159:668-676. [PMID: 38536186 PMCID: PMC10974678 DOI: 10.1001/jamasurg.2024.0118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 01/06/2024] [Indexed: 06/13/2024]
Abstract
Importance Higher lymphedema rates after axillary lymph node dissection (ALND) have been found in Black and Hispanic women; however, there is poor correlation between subjective symptoms, quality of life (QOL), and measured lymphedema. Additionally, racial and ethnic differences in QOL have been understudied. Objective To evaluate the association of race and ethnicity with long-term QOL in patients with breast cancer treated with ALND. Design, Setting, and Participants This cohort study enrolled women aged 18 years and older with breast cancer who underwent unilateral ALND at a tertiary cancer center between November 2016 and March 2020. Preoperatively and at 6-month intervals, arm volume was measured by perometer and QOL was assessed using the Upper Limb Lymphedema-27 (ULL-27) questionnaire, a validated tool for assessing lymphedema that evaluates how arm symptoms affect physical, psychological, and social functioning. Data were analyzed from November 2016 to October 2023. Exposures Breast surgery and unilateral ALND in the primary setting or after sentinel lymph node biopsy. Main Outcomes and Measures Scores in each domain of the ULL-27 were compared by race and ethnicity. Factors impacting QOL were identified using multivariable regression analyses. Results The study included 281 women (median [IQR] age, 48 [41-58] years) with breast cancer who underwent unilateral ALND and had at least 6 months of follow-up. Of these, 30 patients (11%) self-identified as Asian individuals, 57 (20%) as Black individuals, 23 (8%) as Hispanic individuals, and 162 (58%) as White individuals; 9 individuals (3%) who did not identify as part of a particular group or who were missing race and ethnicity data were categorized as having unknown race and ethnicity. Median (IQR) follow-up was 2.97 (1.96-3.67) years. The overall 2-year lymphedema rate was 20% and was higher among Black (31%) and Hispanic (27%) women compared with Asian (15%) and White (17%) women (P = .04). Subjective arm swelling was more common among Asian (57%), Black (70%), and Hispanic (87%) women than White (44%) women (P < .001), and lower physical QOL scores were reported by racial and ethnic minority women at nearly every follow-up. For example, at 24 months, median QOL scores were 87, 79, and 80 for Asian, Black, and Hispanic women compared with 92 for White women (P = .003). On multivariable analysis, Asian race (β = -5.7; 95% CI, -9.5 to -1.8), Hispanic ethnicity (β = -10.0; 95% CI, -15.0 to -5.2), and having Medicaid (β = -5.4; 95% CI, -9.2 to -1.7) or Medicare insurance (β = -6.9; 95% CI, -10.0 to -3.4) were independently associated with worse physical QOL (all P < .001). Conclusions and Relevance Findings of this cohort study suggest that Asian, Black, and Hispanic women experience more subjective arm swelling after unilateral ALND for breast cancer compared with White women. Black and Hispanic women had higher rates of objective lymphedema than their White counterparts. Both minority status and public medical insurance were associated with worse physical QOL. Understanding disparities in QOL after ALND is an unmet need and may enable targeted interventions to improve QOL for these patients.
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Affiliation(s)
- Danielle R. Heller
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Bayley Axelrod
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Varadan Sevilimedu
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Babak J. Mehrara
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrea V. Barrio
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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12
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Copeland-Halperin LR, Hyland CJ, Gadiraju GK, Xiang DH, Bellon JR, Lynce F, Dey T, Troll EP, Ryan SJ, Nakhlis F, Broyles JM. Preoperative Risk Factors for Lymphedema in Inflammatory Breast Cancer. J Reconstr Microsurg 2024; 40:311-317. [PMID: 37751880 DOI: 10.1055/a-2182-1015] [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: 09/28/2023]
Abstract
BACKGROUND Prophylactic lymphatic bypass or LYMPHA (LYmphatic Microsurgical Preventive Healing Approach) is increasingly offered to prevent lymphedema following breast cancer treatment, which develops in up to 47% of patients. Previous studies focused on intraoperative and postoperative lymphedema risk factors, which are often unknown preoperatively when the decision to perform LYMPHA is made. This study aims to identify preoperative lymphedema risk factors in the high-risk inflammatory breast cancer (IBC) population. METHODS Retrospective review of our institution's IBC program database was conducted. The primary outcome was self-reported lymphedema development. Multivariable logistic regression analysis was performed to identify preoperative lymphedema risk factors, while controlling for number of lymph nodes removed during axillary lymph node dissection (ALND), number of positive lymph nodes, residual disease on pathology, and need for adjuvant chemotherapy. RESULTS Of 356 patients with IBC, 134 (mean age: 51 years, range: 22-89 years) had complete data. All 134 patients underwent surgery and radiation. Forty-seven percent of all 356 patients (167/356) developed lymphedema. Obesity (body mass index > 30) (odds ratio [OR]: 2.7, confidence interval [CI]: 1.2-6.4, p = 0.02) and non-white race (OR: 4.5, CI: 1.2-23, p = 0.04) were preoperative lymphedema risk factors. CONCLUSION Patients with IBC are high risk for developing lymphedema due to the need for ALND, radiation, and neoadjuvant chemotherapy. This study also identified non-white race and obesity as risk factors. Larger prospective studies should evaluate potential racial disparities in lymphedema development. Due to the high prevalence of lymphedema, LYMPHA should be considered for all patients with IBC.
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Affiliation(s)
| | - Colby J Hyland
- Department of Surgery, Mass General Brigham, Boston, Massachusetts
| | | | | | - Jennifer R Bellon
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Filipa Lynce
- Department of Medicine, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Tanujit Dey
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Elizabeth P Troll
- Department of Breast Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Sean J Ryan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Faina Nakhlis
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Justin M Broyles
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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Martone P, Kline-Quiroz C, Alpert E, Lee K, Marshall G. Lymphedema Surveillance and Prevention. Am J Phys Med Rehabil 2024; 103:S23-S27. [PMID: 38364026 DOI: 10.1097/phm.0000000000002405] [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: 02/18/2024]
Abstract
ABSTRACT Lymphedema is a chronic condition, which can impact a person's quality of life and function. Identifying lymphedema at an early stage is key to preventing a person from developing chronic lymphedema. Physiatry can play an important role in education, identification of risk factors, performing prospective lymphedema surveillance programs, and prevention/treatment of lymphedema. Incorporating lymphedema surveillance programs into routine cancer care provides physiatry with the opportunity to assess additional rehabilitation and functional needs of a cancer patient.
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Affiliation(s)
- Patrick Martone
- From the Northwell Health, Barbara and Donald Zucker School of Medicine at Hofstra University, Hempstead, New York (PM, EA, KL); Vanderbilt University Medical Center, Nashville, Tennessee (CK-Q); and Memorial Sloan Kettering Cancer Center, New York, NY (GM)
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14
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Azuar AS, Uzan C, Mathelin C, Vignes S. [Update of indications and techniques for the management of lymphedema after breast cancer surgery]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2024; 52:142-148. [PMID: 38190967 DOI: 10.1016/j.gofs.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 12/30/2023] [Indexed: 01/10/2024]
Abstract
OBJECTIVES Upper limb lymphedema secondary to breast cancer treatment is the leading cause of lymphedema in France. Despite improved surgical practices and de-escalation of radiotherapy, the risk of lymphedema after breast cancer still affects 5-20% of patients, with this variation depending on the measurement method used and the population studied. Lymphedema has a negative impact on quality of life and body image, and their possible occurrence remains a major concern for all women treated for breast cancer. The Sénologie Commission of the Collège national des gynécologues et obstétriciens français (CNGOF) asked four specialists in breast surgery or lymphology to prepare a summary on the prevention, medical and surgical management of lymphedema after breast cancer treatment, and to discuss the medical and surgical innovations currently being evaluated. METHODS This synthesis was based on national and international guidelines on the management of upper limb lymphedema after breast surgery and a recent review of the literature focusing on the years 2020-2023. RESULTS From a preventive point of view, the restrictive instructions imposed for a long time (reduction in physical activity or the carrying of loads, air travel, exposure to the sun or cold, etc.) have altered patients' quality of life and should no longer be recommended. A good understanding of risk factors enables us to target preventive actions. Examples include obesity, a sedentary lifestyle, axillary clearance, radiotherapy of the axillary fossa in addition to axillary clearance, total mastectomy, taxanes or anti-HER-2 therapies in the adjuvant phase. Resumption of physical activity, minimally invasive axillary surgery, de-escalation of radiotherapy and breast-conserving surgical procedures have all demonstrated their preventive value. When lymphedema does occur, early management, through complete decongestive physiotherapy, can help reduce its volume and prevent its long-term worsening. CONCLUSION Surgical (lymph node transplants, lympho-vascular anastomoses) and medical (prolymphangiogenic growth factors) approaches to lymphedema treatment are numerous, but require long-term evaluation of their efficacy and adverse effects.
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Affiliation(s)
- Anne-Sophie Azuar
- Service de chirurgie et cancérologie gynécologique et mammaire, centre hospitalier de Grasse, chemin de Clavary, 06130 Grasse, France.
| | - Catherine Uzan
- Service de chirurgie et cancérologie gynécologique et mammaire, hôpital Pitié-Salpêtrière, AP-HP, Sorbonne université, 47-83, boulevard de l'Hôpital, 75013 Paris, France.
| | - Carole Mathelin
- Service de chirurgie, ICANS, avenue Albert-Calmette, 67200 Strasbourg, France; CHRU, avenue Molière, 67200 Strasbourg, France.
| | - Stéphane Vignes
- Unité de lymphologie, Centre de référence des lymphœdèmes primaires, membre de la filière FAVA-Multi et du Réseau européen VASCERN, hôpital de Cognacq-Jay, 15, rue Eugène-Millon, 75015 Paris, France.
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15
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Wang Y, Peng D, Zhou X, Hu W, Li F. Treatments and Prognosis of the Breast Ductal Carcinoma In Situ. Clin Breast Cancer 2024; 24:122-130.e2. [PMID: 38016910 DOI: 10.1016/j.clbc.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 11/06/2023] [Accepted: 11/06/2023] [Indexed: 11/30/2023]
Abstract
INTRODUCTION With progress in treatments, breast ductal carcinoma in situ (DCIS) outcomes have substantially improved. However, as various treatment methods are used in different countries and institutions, consensus on the optimal treatment method is lacking. This study aimed to analyze the prognostic factors and provide a reference for optimizing the clinical treatment of DCIS. PATIENTS AND METHODS This retrospective clinical study collected data from DCIS patients at the Sun Yat-sen University Cancer Center from 2010 to 2017. The Kaplan-Meier method and Cox regression model were used to assess disease-free survival (DFS), overall survival (OS), and local control (LC) rates. RESULTS Among the 483 included patients, 83.6% (404) underwent mastectomies. The median follow-up time was 101 months. The number of patients undergoing breast-conserving surgery (BCS) with radiotherapy has gradually increased. Axillary lymph node dissection was the main surgery performed from 2010 to 2015, and the proportion of sentinel lymph node biopsies (SLNBs) has increased. LC and DFS rates with BCS without radiotherapy were significantly lower than those with mastectomy (P = .002; P < .001). Additionally, the patients who did not undergo axillary surgery had worse LC and OS rates than those who underwent SLNB (P = .028 and P = .038). Endocrine therapy (ET) or its duration had no significant effect on prognosis. CONCLUSION In conclusion, BCS without radiotherapy and lack of axillary surgery were independent prognostic factors. We recommend performing BCS with radiotherapy and SLNB more in clinical practice, as well as shortening the ET duration.
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Affiliation(s)
- Yaxue Wang
- State Key Laboratory of Oncology, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, PR China
| | - Dingsheng Peng
- Department of Radiation Oncology, Huizhou Central People's Hospital, Huizhou, PR China
| | - Xinhui Zhou
- State Key Laboratory of Oncology, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, PR China
| | - Wendie Hu
- State Key Laboratory of Oncology, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, PR China
| | - Fengyan Li
- State Key Laboratory of Oncology, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, PR China.
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陈 君, 邓 呈. [Research advances on stem cell-based treatments in animal studies and clinical trials of lymphedema]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2024; 38:99-106. [PMID: 38225848 PMCID: PMC10796233 DOI: 10.7507/1002-1892.202309045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 12/16/2023] [Indexed: 01/17/2024]
Abstract
Objective To summarize the progress of the roles and mechanisms of various types of stem cell-based treatments and their combination therapies in both animal studies and clinical trials of lymphedema. Methods The literature on stem cell-based treatments for lymphedema in recent years at home and abroad was extensively reviewed, and the animal studies and clinical trials on different types of stem cells for lymphedema were summarized. Results Various types of stem cells have shown certain effects in animal studies and clinical trials on the treatment of lymphedema, mainly through local differentiation into lymphoid endothelial cells and paracrine cytokines with different functions. Current research focuses on two cell types, adipose derived stem cells and bone marrow mesenchymal stem cells, both of which have their own advantages and disadvantages, mainly reflected in the therapeutic effect of stem cells, the difficulty of obtaining stem cells and the content in vivo. In addition, stem cells can also play a synergistic role in combination with other treatments, such as conservative treatment, surgical intervention, cytokines, biological scaffolds, and so on. However, it is still limited to the basic research stage, and only a small number of studies have completed clinical trials. Conclusion Stem cells have great transformation potential in the treatment of lymphedema, but there is no unified standard in the selection of cell types, the amount of transplanted cells, and the timing of transplantation.
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Affiliation(s)
- 君哲 陈
- 遵义医科大学附属医院烧伤整形外科(贵州遵义 563003)Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi Guizhou, 563003, P. R. China
| | - 呈亮 邓
- 遵义医科大学附属医院烧伤整形外科(贵州遵义 563003)Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi Guizhou, 563003, P. R. China
- 组织损伤修复与再生医学省部共建协同创新中心(贵州遵义 563003)Collaborative Innovation Center of Tissue Repair and Regenerative Medicine, Zunyi Guizhou, 563003, P. R. China
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17
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Sun SX, Piotrowski MJ, Adesoye T, Mitchell MP, Garber HR, Teshome M, Kuerer HM, Tamirisa N, Singh P. Long-Term Outcomes and Predictors of Response in Breast Cancer Patients with Advanced Nodal Involvement. J Am Coll Surg 2024; 238:1-9. [PMID: 37870227 DOI: 10.1097/xcs.0000000000000872] [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: 10/24/2023]
Abstract
BACKGROUND Advanced nodal disease is associated with poor prognosis. However, modern neoadjuvant systemic therapy (NST) regimens have resulted in higher pathologic complete response (pCR) rates, which are associated with improved survival. We sought to assess contemporary outcomes in patients with advanced nodal involvement and response to NST. STUDY DESIGN We conducted a single-institution, retrospective study of 521 patients with cN2-3 primary nonmetastatic breast cancer treated with NST followed by surgery and radiation from 2012 to 2018. Descriptive statistics, multivariate Cox regression, and Kaplan-Meier analyses were performed. RESULTS The mean age was 50.5 years, and median follow-up was 61 (4.7 to 197) months. The majority of patients had hormone receptor-positive (HR+)/HER2-negative tumors (HER2-; n = 242, 47.8%). Most were cT2 (n = 243; 46.6%) or cT3 (n = 139; 26.7%) and 73.3% (n = 382) had cN3 disease. Rate of axillary pCR was 34.2%, and breast and axillary pCR was 19.4% (n = 101). Event-free survival (EFS) at 5 years was 75.1% (95% CI, 0.71 to 0.79). Rate of locoregional recurrence was 6.7%; distant metastatic rate was 29.4%. Axillary pCR with or without breast pCR was significantly associated with longer EFS (p = 0.001). Achieving breast/axillary pCR was an independent predictor of improved EFS (hazard ratio 0.22, p < 0.0001). Having triple-negative disease was associated with worse EFS (hazard ratio 1.74, p = 0.008). CONCLUSIONS In a high-risk cohort of patients with cN2-3 disease, trimodality therapy was effective in achieving durable EFS. Approximately one-third of patients achieved axillary pCR, which was associated with improved survival. Further studies are needed to accurately determine axillary response in cN2-3 breast cancer after NST in order to develop de-escalation strategies to reduce morbidity associated with axillary surgery.
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Smedsland SK, Falk RS, Reinertsen KV, Kiserud CE, Brekke M, Bøhn SH, Dahl AA, Vandraas KF. Burden of late effects in a nationwide sample of long-term breast cancer survivors. Cancer 2024; 130:140-149. [PMID: 37776533 DOI: 10.1002/cncr.35019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 07/24/2023] [Accepted: 08/08/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND Long-term breast cancer survivors (BCSs) may experience several late effects (LEs) simultaneously. This study aimed to identify subgroups of 8-year BCSs with higher burden of LEs who could benefit from closer survivorship care, explore variables associated with higher symptom burden, and describe how symptom burden may affect general functioning. METHODS All Norwegian women aged 20 to 65 years when diagnosed with stage I-III breast cancer in 2011 and 2012 were invited (n = 2803). The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire/BR23, the Fatigue Questionnaire, Assessment of Survivor Concerns, and Scale for Chemotherapy Induced Long-term Neurotoxicity were used to assess 10 common LEs and general functioning. Using latent class analysis, subgroups of BCSs with similar burden of LEs were identified. Multinominal regression analysis were performed to examine variables associated with higher symptom burden. RESULTS The final sample consisted of 1353 BCSs; 46% had low, 37% medium, and 17% high symptom burden. Younger age, short education, axillary dissection, higher systemic treatment burden, higher body mass index, and physical inactivity were associated with higher symptom burden. General functioning scores were lower, and the proportion on disability pension were higher among BCSs in the two most burdened subgroups compared with those in the low burden subgroup. CONCLUSION More than half of long-term BCSs suffered from medium or high symptom burden and experienced impaired general functioning compared with BCS with low symptom burden. Younger age and systemic treatment were important risk factors for higher symptom burden. BCSs at risk of higher symptom burdens should be identified and offered closer and extended survivorship care.
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Affiliation(s)
- Solveig K Smedsland
- Department of Oncology, National Advisory Unit for Late Effects After Cancer Treatment, Oslo University Hospital, Oslo, Norway
- Department of Community Medicine and Global Health, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Ragnhild S Falk
- Oslo Centre for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway
| | - Kristin V Reinertsen
- Department of Oncology, National Advisory Unit for Late Effects After Cancer Treatment, Oslo University Hospital, Oslo, Norway
| | - Cecilie E Kiserud
- Department of Oncology, National Advisory Unit for Late Effects After Cancer Treatment, Oslo University Hospital, Oslo, Norway
| | - Mette Brekke
- General Practice Research Unit, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Synne H Bøhn
- Department of Oncology, National Advisory Unit for Late Effects After Cancer Treatment, Oslo University Hospital, Oslo, Norway
| | - Alv A Dahl
- Department of Oncology, National Advisory Unit for Late Effects After Cancer Treatment, Oslo University Hospital, Oslo, Norway
| | - Kathrine F Vandraas
- Department of Oncology, National Advisory Unit for Late Effects After Cancer Treatment, Oslo University Hospital, Oslo, Norway
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Engin A. Obesity-Associated Breast Cancer: Analysis of Risk Factors and Current Clinical Evaluation. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1460:767-819. [PMID: 39287872 DOI: 10.1007/978-3-031-63657-8_26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/19/2024]
Abstract
Several studies show that a significantly stronger association is obvious between increased body mass index (BMI) and higher breast cancer incidence. Additionally, obese and postmenopausal women are at higher risk of all-cause and breast cancer-specific mortality compared with non-obese women with breast cancer. In this context, increased levels of estrogens, excessive aromatization activity of the adipose tissue, overexpression of pro-inflammatory cytokines, insulin resistance, adipocyte-derived adipokines, hypercholesterolemia, and excessive oxidative stress contribute to the development of breast cancer in obese women. Genetic evaluation is an integral part of diagnosis and treatment for patients with breast cancer. Despite trimodality therapy, the four-year cumulative incidence of regional recurrence is significantly higher. Axillary lymph nodes as well as primary lesions have diagnostic, prognostic, and therapeutic significance for the management of breast cancer. In clinical setting, because of the obese population primary lesions and enlarged lymph nodes could be less palpable, the diagnosis may be challenging due to misinterpretation of physical findings. Thereby, a nomogram has been created as the "Breast Imaging Reporting and Data System" (BI-RADS) to increase agreement and decision-making consistency between mammography and ultrasonography (USG) experts. Additionally, the "breast density classification system," "artificial intelligence risk scores," ligand-targeted receptor probes," "digital breast tomosynthesis," "diffusion-weighted imaging," "18F-fluoro-2-deoxy-D-glucose positron emission tomography," and "dynamic contrast-enhanced magnetic resonance imaging (MRI)" are important techniques for the earlier detection of breast cancers and to reduce false-positive results. A high concordance between estrogen receptor (ER) and progesterone receptor (PR) status evaluated in preoperative percutaneous core needle biopsy and surgical specimens is demonstrated. Breast cancer surgery has become increasingly conservative; however, mastectomy may be combined with any axillary procedures, such as sentinel lymph node biopsy (SLNB) and/or axillary lymph node dissection whenever is required. As a rule, SLNB-guided axillary dissection in breast cancer patients who have clinically axillary lymph node-positive to node-negative conversion following neoadjuvant chemotherapy is recommended, because lymphedema is the most debilitating complication after any axillary surgery. There is no clear consensus on the optimal treatment of occult breast cancer, which is much discussed today. Similarly, the current trend in metastatic breast cancer is that the main palliative treatment option is systemic therapy.
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Affiliation(s)
- Atilla Engin
- Faculty of Medicine, Department of General Surgery, Gazi University, Besevler, Ankara, Turkey.
- Mustafa Kemal Mah. 2137. Sok. 8/14, 06520, Cankaya, Ankara, Turkey.
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Shen A, Qiang W, Zhang L, Bian J, Zhu F, Zhang Z, Lu Q. Risk Factors for Breast Cancer-Related Lymphedema: An Umbrella Review. Ann Surg Oncol 2024; 31:284-302. [PMID: 37725224 DOI: 10.1245/s10434-023-14277-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 08/25/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Identification of risk factors facilitates the prevention of breast cancer-related lymphedema (BCRL). Several published systematic reviews have already addressed the risk factors for BCRL. This study aimed to systematically identify potential risk factors for BCRL and evaluate the quality of evidence. METHODS The study followed methodologic guidance from the Joanna Briggs Institute, and the Cochrane Handbook. The following electronic databases were systematically searched from inception to 15 November 2022: PubMed, Embase, CINAHL, Web of Science, Scopus, CNKI, SinoMed, Wanfang, JBI Database, Cochrane Database, ProQuest, and PROSPERO. Two authors independently screened studies, extracted data, and assessed methodologic quality using AMSTAR2, risk of bias using ROBIS, and evidence quality using GRADE. The study evaluated overlap, assessed the small-study effect, and calculated the I2 statistic and Egger's P value as needed. RESULTS The study included 14 publications comprising 10 meta-analyses and 4 systematic reviews. The authors identified 39 factors and 30 unique meta-analyses. In the study, 13 innate personal trait-related risk factors, such as higher body mass index (BMI) and axillary lymph nodes dissection, showed statistically significant associations with BCRL incidence. Breast reconstruction was found to be a protective factor. The methodologic quality was low or critically low. The majority of the systematic reviews and/or meta-analyses were rated as having a high risk of bias. Evidence quality was low for 22 associations and moderate for 8 associations. CONCLUSIONS The currently identified risk factors for BCRL all are innate personal trait-related factors. Future well-designed studies and robust meta-analyses are needed to explore potential associations between behavioral-, interpersonal-, and environmental-related factors and BCRL, as well as the role of genetic variations and pathophysiologic factors.
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Affiliation(s)
- Aomei Shen
- Department of Nursing, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- Division of Medical and Surgical Nursing, School of Nursing, Peking University, Beijing, China
- Peking University Health Science Centre for Evidence-Based Nursing: A Joanna Briggs Institute Affiliated Group, Beijing, China
| | - Wanmin Qiang
- Department of Nursing, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Liyuan Zhang
- Department of Nursing, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Jingru Bian
- Department of Nursing, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Fei Zhu
- School of Nursing, Hebei University, Baoding, China
| | - Zijuan Zhang
- Division of Medical and Surgical Nursing, School of Nursing, Peking University, Beijing, China
- Peking University Health Science Centre for Evidence-Based Nursing: A Joanna Briggs Institute Affiliated Group, Beijing, China
| | - Qian Lu
- Division of Medical and Surgical Nursing, School of Nursing, Peking University, Beijing, China.
- Peking University Health Science Centre for Evidence-Based Nursing: A Joanna Briggs Institute Affiliated Group, Beijing, China.
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da Silva Tozzo FCB, Sarri AJ, Pirola WE, da Silva UBC, de Oliveira MA, de Pádua Souza C, da Costa Vieira RA. Evaluation of upper limb lymphoedema and diagnostic accuracy of bioimpedance spectroscopy. A comprehensive validation in a Brazilian population. Ecancermedicalscience 2023; 17:1649. [PMID: 38419858 PMCID: PMC10901233 DOI: 10.3332/ecancer.2023.1649] [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: 09/13/2023] [Indexed: 03/02/2024] Open
Abstract
Lymphoedema is a complication of breast cancer treatment. Its early diagnosis is related to a good prognosis for lymphoedema treatment. The bioimpedance spectroscopy (BIS) evaluates changes in extracellular fluid. The objective of our study was to evaluate the validity, agreement and accuracy of BIS in the diagnosis of breast cancer-related lymphoedema in a Brazilian population. Methods This is a prospective, cross-sectional study of a convenience sample of 462 women who underwent surgical treatment for breast cancer (mastectomy or breast-conserving treatment). The validity, agreement and accuracy were performed comparing BIS (lymphoedema index (L-DEX) ≥ 6.5 or 10) with volumetry by water displacement, which is the gold standard for evaluating lymphoedema. Receiver operating characteristic curve was performed. Additionally, other methods like perimetry and indirect volumetry of the upper limbs were compared with water displacement volumetry (direct volumetry), and the BIS were compared with subjective evaluation. Results Considering L-DEX ≥ 10 the sensitivity of the BIS was 44.1%, specificity 95.4%, positive predictive value (PPV) was 70.7%, negative predictive value (NPV) was 87% and kappa was 0.459. The BIS with L-DEX ≥ 6.5, the sensitivity, specificity, PPV, NPV and kappa were 57%, 88.5%, 55.8%, 89% and 0.452, respectively. Area under curve was 0.724 and a possible cut-off point of L-DEX ≥ 7.35 with sensitivity of 57%, specificity of 90.7% and kappa value = 0.489. Conclusion Although BIS was significantly associated with the subjective evaluation of lymphoedema, it showed low sensitivity and agreement and moderate correlation when used as a method for diagnosing the condition. Thus, it is not the most valid method for evaluating lymphoedema. In addition, it was not the most accurate method when compared with other objective evaluation tools. Public health resources are scarce and must be used consciously. The knowledge that BIS is not a more accurate method than other, lower-cost instruments allows for better targeting of these resources.
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Affiliation(s)
| | - Almir José Sarri
- Department of Physical Therapy, Barretos Cancer Hospital, São Paulo 14784-390, Brazil
- https://orcid.org/0000-0001-9184-584X
| | - Willian Eduardo Pirola
- Post-Graduate Program, Barretos Cancer Hospital, São Paulo 14784-400, Brazil
- https://orcid.org/0000-0003-3372-2504
| | | | - Marco Antonio de Oliveira
- Center of Epidemiology and Biostatistics, Barretos Cancer Hospital, São Paulo 14784-400, Brazil
- https://orcid.org/0000-0001-6879-2778
| | - Cristiano de Pádua Souza
- Post-Graduate Program, Barretos Cancer Hospital, São Paulo 14784-400, Brazil
- https://orcid.org/0000-0002-6412-8041
| | - René Aloisio da Costa Vieira
- Post-Graduate Program, Barretos Cancer Hospital, São Paulo 14784-400, Brazil
- Department of Breast Cancer, Barretos Cancer Hospital, São Paulo 14784-400, Brazil
- https://orcid.org/0000-0003-2014-9016
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22
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Marco E, Trépanier G, Chang E, Mauti E, Jones JM, Zhong T. Postmastectomy Functional Impairments. Curr Oncol Rep 2023; 25:1445-1453. [PMID: 37955831 PMCID: PMC10728246 DOI: 10.1007/s11912-023-01474-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2023] [Indexed: 11/14/2023]
Abstract
PURPOSE OF REVIEW This narrative review aims to offer a thorough summary of functional impairments commonly encountered by breast cancer survivors following mastectomy. Its objective is to discuss the factors influencing these impairments and explore diverse strategies for managing them. RECENT FINDINGS Postmastectomy functional impairments can be grouped into three categories: neuromuscular, musculoskeletal, and lymphovascular. Neuromuscular issues include postmastectomy pain syndrome (PMPS) and phantom breast syndrome (PBS). Musculoskeletal problems encompass myofascial pain syndrome and adhesive capsulitis. Lymphovascular dysfunctions include lymphedema and axillary web syndrome (AWS). Factors such as age, surgical techniques, and adjuvant therapies influence the development of these functional impairments. Managing functional impairments requires a comprehensive approach involving physical therapy, pharmacologic therapy, exercise, and surgical treatment when indicated. It is important to identify the risk factors associated with these conditions to tailor interventions accordingly. The impact of breast reconstruction on these impairments remains uncertain, with mixed results reported in the literature.
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Affiliation(s)
- Eden Marco
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
| | | | - Eugene Chang
- Department of Medicine, Division of Physical Medicine & Rehabilitation, University of Toronto, Toronto, ON, Canada
- Department of Supportive Care, Cancer Rehab & Survivorship Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Multisystem & Musculoskeletal Rehabilitation Program, Toronto Rehabilitation Institute, Toronto, ON, Canada
| | - Emma Mauti
- Department of Medicine, Division of Physical Medicine & Rehabilitation, University of Toronto, Toronto, ON, Canada
| | - Jennifer M Jones
- Cancer Rehabilitation and Survivorship Program, Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Toni Zhong
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
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23
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Kim N, Kim H, Hwang JH, Lee JE, Park W, Cho WK, Nam SJ, Kim SW, Yu J, Chae BJ, Lee SK, Ryu JM, Im YH, Ahn JS, Park YH, Kim JY, Kim TG. Incidence of and Influencing Factors for Arm Lymphedema After Salvage Treatment for an Isolated Locoregional Recurrence of Breast Cancer. J Breast Cancer 2023; 26:544-557. [PMID: 37985381 PMCID: PMC10761755 DOI: 10.4048/jbc.2023.26.e43] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 07/03/2023] [Accepted: 09/25/2023] [Indexed: 11/22/2023] Open
Abstract
PURPOSE Data on subsequent arm lymphedema (SAL) after salvage treatment for locoregional recurrence (LRR) of breast cancer are limited. We conducted a study to evaluate the risk of SAL in patients with LRR. METHODS We reviewed the data of patients with breast cancer who had LRR and were initially diagnosed between January 2003 and December 2017. Among the 214 patients who received curative salvage treatment, most had local (n = 125, 57.9%), followed by regional (n = 73, 34.1%), and locoregional (n = 16, 7.9%) recurrences. A competing risk analysis considering the factors of death and a second LRR were performed to exclude potential malignant lymphedema. We used the Fine-Gray subdistribution hazards model to estimate the hazard ratio (HR) for comparing the risk of SAL. RESULTS With a median follow-up duration of 41.4 months (interquartile range, 25.6-65.1), 51 patients (23.8%) experienced SAL with a median interval of 9.9 months after treatment. The two-year cumulative incidence of SAL was 12.7%. Among the 18 patients with initial lymphedema, nine (50.0%) developed SAL. Multivariate analysis revealed that a history of lymphedema (HR, 4.61; p < 0.001) and taxane-based salvage chemotherapy (HR, 2.38; p = 0.009) were significantly associated with SAL development. CONCLUSION Salvage treatment for LRR-induced SAL was performed in 24% of the patients. A history of initial lymphedema and salvage taxane-based chemotherapy increases the risk of developing SAL. Therefore, close surveillance for the incidence of SAL is required in patients opting for salvage treatment for LRR.
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Affiliation(s)
- Nalee Kim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Haeyoung Kim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Ji Hye Hwang
- Department of Physical & Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Jeong Eon Lee
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Won Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Won Kyung Cho
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seok Jin Nam
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seok Won Kim
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jonghan Yu
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Byung Joo Chae
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Se Kyung Lee
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jai Min Ryu
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young-Hyuck Im
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Seok Ahn
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yeon Hee Park
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji-Yeon Kim
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae-Gyu Kim
- Department of Radiation Oncology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
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Gülören G, Doğan Y, Özgül S, Gürşen C, Çinar GN, İpekten F, Akbayrak T. Acute Effects of Remedial Exercises with and without Compression on Breast-Cancer-Related Lymphedema. Healthcare (Basel) 2023; 11:2949. [PMID: 37998441 PMCID: PMC10671079 DOI: 10.3390/healthcare11222949] [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: 09/21/2023] [Revised: 11/06/2023] [Accepted: 11/09/2023] [Indexed: 11/25/2023] Open
Abstract
Remedial exercises are an important part of the treatment for lymphedema, but there is little evidence to support the acute effects of remedial exercises with or without compression. The aim of this study was to investigate whether and how daily (performed within 24 h) remedial exercises with and without compression bandaging acutely affect the severity of lymphedema and its symptoms in breast-cancer-related lymphedema (BCRL). In total, 34 patients with BCRL completed three sets of remedial exercises (within 24 h) with and without compression bandaging in a randomized order separated by a 3-day wash-out period. The severity of lymphedema and extracellular water ratio were assessed before and 24 h post exercise by using bilateral circumferential measurements and bioimpedance spectroscopy (in L-dex score), respectively, and the severity of self-reported symptoms (swelling, heaviness, and tightness) was assessed using a visual analogue scale. While there was no difference in all outcomes at 24 h post exercise without compression (p > 0.05), all outcomes decreased significantly compared to baseline at 24 h after the exercise with compression (p < 0.001). The remedial exercises performed in the absence of compression within 24 h do not acutely increase the lymphedema and symptoms in BCRL. These are important preliminary findings, which can be used to inform future prospective evaluation of the long-term effects of remedial exercise performed without compression.
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Affiliation(s)
- Gülbala Gülören
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara 06100, Turkey; (Y.D.); (S.Ö.); (C.G.); (G.N.Ç.); (T.A.)
| | - Yahya Doğan
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara 06100, Turkey; (Y.D.); (S.Ö.); (C.G.); (G.N.Ç.); (T.A.)
| | - Serap Özgül
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara 06100, Turkey; (Y.D.); (S.Ö.); (C.G.); (G.N.Ç.); (T.A.)
| | - Ceren Gürşen
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara 06100, Turkey; (Y.D.); (S.Ö.); (C.G.); (G.N.Ç.); (T.A.)
| | - Gamze Nalan Çinar
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara 06100, Turkey; (Y.D.); (S.Ö.); (C.G.); (G.N.Ç.); (T.A.)
| | - Funda İpekten
- Department of Biostatistics, Faculty of Medicine, Erciyes University, Kayseri 38039, Turkey;
| | - Türkan Akbayrak
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara 06100, Turkey; (Y.D.); (S.Ö.); (C.G.); (G.N.Ç.); (T.A.)
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25
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Shen A, Wu P, Qiang W, Fu X, Zhu F, Pang L, Wang F, Lu Q. Factors associated with lymphedema self-management behaviours among breast cancer survivors: A cross-sectional study. J Clin Nurs 2023; 32:7330-7345. [PMID: 37491890 DOI: 10.1111/jocn.16833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 05/05/2023] [Accepted: 07/10/2023] [Indexed: 07/27/2023]
Abstract
AIMS AND OBJECTIVES The purpose of this empirical study was to explore the current status and associated factors of lymphedema self-management behaviours among Chinese breast cancer survivors. BACKGROUND Breast cancer-related lymphedema is a lifetime concern for survivors and is currently incurable. Lifetime lymphedema self-management takes a significant role in preventing development and progression of lymphedema. Understanding influencing factors of lymphedema self-management behaviours can help to develop targeted intervention programs. DESIGN A multicentre cross-sectional study. METHODS From December 2021 to April 2022, a convenience sample of 586 participants were recruited at four tertiary hospitals in four cities in China. Self-reported questionnaires were used to measure socio-demographic characteristics, disease-and treatment-related characteristics, lymphedema self-management behaviours, lymphedema knowledge, illness perception, self-efficacy, self-regulation and social support. Descriptive analysis, bivariate analysis and hierarchical multiple regression were conducted. This study was registered at Chinese Clinical Trial Registry (ChiCTR2200057084), and was reported followed the STROBE checklist. RESULTS Breast cancer survivors reported moderate level of lymphedema self-management behaviours. Promotion of lymph reflux management was ranked the least performed self-management behaviours, while the affected limb protection management ranked the most. 36.2% of self-management behaviours was explained by exercise regularly, level of attention on lymphedema prevention, unclear about the tumour stage (vs. stage I), knowledge, self-efficacy, emotional illness representation and social support. CONCLUSIONS Lymphedema self-management behaviours of breast cancer survivors was insufficient. Performance of lymphedema self-management varied with different socio-demographic characteristics, along with different levels of knowledge, self-efficacy, perception and social support. All these identified predictors should be reckoned in assessment and intervention of lymphedema self-management behaviours. RELEVANCE TO CLINICAL PRACTICE This study addressed that breast cancer survivors' lymphedema self-management behaviours should be promoted. Focusing on identified predictors, further lymphedema surveillance, knowledge education or social facilitation programs are recommended to enhance their self-management performance and adherence.
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Affiliation(s)
- Aomei Shen
- Department of Nursing, Tianjin Medical University Cancer Institute & Hospital, Tianjin, China
- Division of Medical & Surgical Nursing, School of Nursing, Peking University, Beijing, China
| | - Peipei Wu
- Lymphedema Clinic, Tianjin Medical University Cancer Institute & Hospital, Tianjin, China
| | - Wanmin Qiang
- Department of Nursing, Tianjin Medical University Cancer Institute & Hospital, Tianjin, China
| | - Xin Fu
- Division of Medical & Surgical Nursing, School of Nursing, Peking University, Beijing, China
| | - Fei Zhu
- School of Nursing, Hebei University, Baoding, China
| | - Lisha Pang
- School of Nursing, Hebei University, Baoding, China
| | - Fangfang Wang
- Department of Nursing, Shanxi Provincial Cancer Hospital, Taiyuan, China
| | - Qian Lu
- Division of Medical & Surgical Nursing, School of Nursing, Peking University, Beijing, China
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26
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Naoum GE, Taghian AG. Regional Lymph Node Radiation Is Not the Main Risk Factor for Breast Cancer Related Lymphedema: Stop Chasing Radiation Doses, Fractionation or Techniques-Focus on Axillary Surgery De-escalation or Prevention. Int J Radiat Oncol Biol Phys 2023; 117:461-464. [PMID: 37652608 DOI: 10.1016/j.ijrobp.2023.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/14/2023] [Accepted: 04/20/2023] [Indexed: 09/02/2023]
Affiliation(s)
- George E Naoum
- Department of Radiation Oncology, Northwestern University Memorial Hospital, Chicago, Illinois.
| | - Alphonse G Taghian
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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27
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Pride RM, Glass CC, Nakhlis F, Laws A, Weiss AC, Bellon JR, Mittendorf EA, King TA, Kantor O. Intraoperative Pathology Assessment May Lead to Overtreatment of the Axilla in Clinically Node-Negative Breast Cancer Patients Undergoing Upfront Mastectomy. Ann Surg Oncol 2023; 30:5978-5987. [PMID: 37436607 DOI: 10.1245/s10434-023-13898-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 06/22/2023] [Indexed: 07/13/2023]
Abstract
BACKGROUND Randomized trials have established the safety of observation or axillary radiation (AxRT) as an alternative to axillary lymph node dissection (ALND) in patients with limited nodal disease who undergo upfront surgery. Variability remains in axillary management strategies in cN0 patients undergoing mastectomy found to have one to two positive sentinel lymph nodes (SLNs). We examined the impact of intraoperative pathology assessment in axillary management in a national cohort of AMAROS-eligible mastectomy patients. METHODS The National Cancer Database was used to identify AMAROS-eligible cT1-2N0 breast cancer patients undergoing upfront mastectomy and SLN biopsy (SLNB) and found to have one to two positive SLNs, from 2018 to 2019. We constructed a variable defining intraoperative pathology as 'not performed/not acted on' if ALND was either not performed or performed at a later date than SLNB, or 'performed/acted on' if SLNB and ALND were completed on the same day. Adjusted multivariable analysis examined predictors of treatment with both ALND and AxRT. RESULTS Overall, 8222 patients with cT1-2N0 disease underwent upfront mastectomy and had one to two positive SLNs. Intraoperative pathology was performed/acted on in 3057 (37.2%) patients. These patients were significantly more likely to have both ALND and AxRT than those without intraoperative pathology (41.0% vs. 4.9%; p < 0.001). On multivariate analysis, the strongest predictor of receiving both ALND and AxRT was use of intraoperative pathology (odds ratio 8.99, 95% confidence interval 7.70-10.5; p < 0.001). CONCLUSIONS We advocate that consideration should be made for omission of routine intraoperative pathology in mastectomy patients likely to be recommended postmastectomy radiation to minimize axillary overtreatment with both ALND and AxRT in appropriate patients.
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Affiliation(s)
- Robert M Pride
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
| | - Charity C Glass
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
| | - Faina Nakhlis
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Alison Laws
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Anna C Weiss
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Jennifer R Bellon
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, MA, USA
| | - Elizabeth A Mittendorf
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Tari A King
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Olga Kantor
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
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28
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Jeffers EJ, Wagner JL, Kilgore LJ. ASO Author Reflections: Breast Cancer-Related Lymphedema (BCRL) Surveillance Recommendations with Bioimpedance Spectroscopy. Ann Surg Oncol 2023; 30:6266-6267. [PMID: 37612546 DOI: 10.1245/s10434-023-14099-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 07/24/2023] [Indexed: 08/25/2023]
Affiliation(s)
- Elizabeth J Jeffers
- Division of Breast Surgical Oncology, Department of Surgery, University of Kansas Cancer Center, Kansas City, KS, USA
| | - Jamie L Wagner
- Division of Breast Surgical Oncology, Department of Surgery, University of Kansas Cancer Center, Kansas City, KS, USA
| | - Lyndsey J Kilgore
- Division of Breast Surgical Oncology, Department of Surgery, University of Kansas Cancer Center, Kansas City, KS, USA.
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Healy E, Beyer S, Jhawar S, White JR, Bazan JG. The Axillary Lateral Vessel Thoracic Junction Is Not an Organ at Risk for Breast Cancer-Related Lymphedema. Int J Radiat Oncol Biol Phys 2023; 117:452-460. [PMID: 37059233 DOI: 10.1016/j.ijrobp.2023.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 03/21/2023] [Accepted: 04/03/2023] [Indexed: 04/16/2023]
Abstract
PURPOSE Breast cancer-related lymphedema (BCRL) is a treatment complication that significantly reduces patient quality of life. Regional nodal irradiation (RNI) may increase the risk of BCRL. Recently, a region of the axilla known as the axillary-lateral thoracic vessel juncture (ALTJ) was identified as a potential organ at risk (OAR). Here, we set out to validate whether radiation dose to the ALTJ is associated with BCRL. METHODS AND MATERIALS We identified patients with stage II-III breast cancer treated with adjuvant RNI from 2013 to 2018, excluding those with BCRL preradiation. We defined BCRL as difference in arm circumference between the ipsilateral and contralateral limb >2.5 cm at any 1 encounter or ≥2 cm on ≥2 visits. All patients suspected of having BCRL at routine follow-up visits were referred to physical therapy for confirmation. The ALTJ was retrospectively contoured and dose metrics were collected. Cox proportional hazards regression models were used to test the association between clinical and dosimetric parameters with the development of BCRL. RESULTS The study population included 378 patients with a median age of 53 years, median body mass index of 28.4 kg/m2, and median of 18 axillary nodes removed; 71% underwent mastectomy. Median follow-up was 70 months (interquartile range, 55-89.7 months). BCRL developed in 101 patients at a median of 18.9 months (interquartile range, 9.9-32.4 months), with a corresponding 5-year cumulative incidence BCRL of 25.8%. On multivariate analysis, none of the ALTJ metrics were associated with BCRL risk. Only increasing age, increasing body mass index, and increasing number of nodes were associated with a higher risk of developing BCRL. The 6-year locoregional recurrence rate was 3.2%, the axillary recurrence rate was 1.7%, and the isolated axillary recurrence rate was 0%. CONCLUSIONS The ALTJ is not validated as a critical OAR for reducing BCRL risk. Until such an OAR is discovered, the axillary PTV should not be modified or dose reduced in efforts to reduce BCRL.
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Affiliation(s)
- Erin Healy
- Department of Radiation Oncology, UCI Chao Family Comprehensive Cancer Center, Orange, California; Department of Radiation Oncology, Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Sasha Beyer
- Department of Radiation Oncology, Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Sachin Jhawar
- Department of Radiation Oncology, Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Julia R White
- Department of Radiation Oncology, University of Kansas Comprehensive Cancer Center, Kansas City, Kansas
| | - Jose G Bazan
- Department of Radiation Oncology, UCI Chao Family Comprehensive Cancer Center, Orange, California; Department of Radiation Oncology, Ohio State University Comprehensive Cancer Center, Columbus, Ohio; Department of Radiation Oncology, City of Hope Comprehensive Cancer Center, Duarte, California.
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30
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Soran A, Bengur FB, Rodriguez W, Chroneos MZ, Sezgin E. Early Detection of Breast Cancer-Related Lymphedema: Accuracy of Indocyanine Green Lymphography Compared with Bioimpedance Spectroscopy and Subclinical Lymphedema Symptoms. Lymphat Res Biol 2023; 21:359-365. [PMID: 36946918 DOI: 10.1089/lrb.2022.0066] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
Introduction: The reported incidences of breast cancer-related lymphedema (LE) affecting the arms vary greatly. Reason for this variability includes different diagnostic techniques used across studies. In the current study, we compared the accuracy of indocyanine green lymphography (ICG_L) and bioimpedance spectroscopy (BIS) in detecting LE before presentation of clinical signs. Methods and Results: Patients with no initial detectable signs of clinical LE of their arms after axillary lymph node dissection or removal of >5 lymph nodes on sentinel lymph node biopsy were included. Subclinical LE was defined as BIS values outside the normal range [(≥7 units (or >10 units)] or a 7-unit (or 10 unit) change between two measurements. We tracked ICG_L and BIS measurements for 133 potentially affected arms (n = 123). ICG_L detected signs of lymphatic flow disruption in 63 arms (47%). Based on the BIS value of 7 units, 60 arms (45%) had values outside the normal range. When using ICG_L-identified LE cases as true positives, BIS had a 54% accuracy (area under the curve [AUC] = 0.54) in detecting LE. Accuracy was 61% for subclinical LE symptoms when compared with ICG_L (AUC = 0.62). Both BIS and subclinical LE symptoms had <0.70 AUC-receiver characteristic operator curve, suggesting that BIS and development of subclinical LE symptoms are not adequate for identifying patients with subclinical LE. Conclusion: ICG_L is a reliable diagnostic tool for detecting early signs of lymphatic flow disruption in subclinical LE. Utilizing ICG_L to diagnose subclinical LE followed by a personalized treatment plan may provide patients the best chance of preventing disease progression.
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Affiliation(s)
- Atilla Soran
- Comprehensive Lymphedema Program, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Surgery and University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Fuat Baris Bengur
- Department of Plastic and Reconstructive Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Wendy Rodriguez
- Comprehensive Lymphedema Program, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Maria Z Chroneos
- Department of Surgery and University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Efe Sezgin
- Department of Food Engineering, Izmir Institute of Technology, Izmir, Turkey
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Aguilera-Eguía RA, Gutiérrez-Arias R, Zaror C, Seron P. Effectiveness of physical exercise programmes in reducing complications associated with secondary lymphoedema to breast cancer: a protocol for an overview of systematic reviews. BMJ Open 2023; 13:e071630. [PMID: 37429694 PMCID: PMC10335487 DOI: 10.1136/bmjopen-2023-071630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 06/23/2023] [Indexed: 07/12/2023] Open
Abstract
INTRODUCTION Breast cancer-related lymphoedema (BCRL) is one of the most underestimated and debilitating complications associated with the treatment that women with breast cancer receive. Several systematic reviews (SRs) of different physical exercise programmes have been published, presenting disperse and contradictory clinical results. Therefore, there is a need for access to the best available and summarised evidence to capture and evaluate all the physical exercise programmes that focus on reducing BCRL. OBJECTIVE To evaluate the effectiveness of different physical exercise programmes in reducing the volume of lymphoedema, pain intensity and improving quality of life. METHOD AND ANALYSIS The protocol of this overview is reported following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols, and its methodology is based on Cochrane Handbook for Systematic Reviews of Interventions. Only those SRs involving physical exercise by patients with BCRL will be included, whether on its own or combined with other exercises or other physical therapy interventions.The outcomes of interest to be considered will be lymphoedema volume, quality of life, pain intensity, grip strength, range of motion, upper limb function and any adverse event. The MEDLINE/PubMed, Lilacs, Cochrane Library, PEDro and Embase databases will be searched for reports published from database inception to April 2023.Two researchers will perform study selection, data extraction and risk of bias assessment independently. Any discrepancy will be resolved by consensus, or ultimately, by a third-party reviewer. We will use Grading of Recommendations Assessment, Development and Evaluation System to assess the overall quality of the body of evidence. ETHICS AND DISSEMINATION The results of this overview will be published in peer-reviewed scholarly journals and the scientific dissemination will take place in national or international conferences. This study does not require approval from an ethics committee, as it does not directly collect information from patients. PROSPERO REGISTRATION NUMBER CRD42022334433.
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Affiliation(s)
- Raúl Alberto Aguilera-Eguía
- Departamento de Salud Pública, Facultad de Medicina, Universidad Católica de la Santísima Concepción, Concepcion, Chile
- Department of Paediatrics, Obstetrics and Gynaecology and Preventive Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ruvistay Gutiérrez-Arias
- Departamento de Apoyo en Rehabilitación Cardiopulmonar Integral, Instituto Nacional del Tórax, Santiago, Chile
- Exercise and Rehabilitation Sciences Institute, Faculty of Rehabilitation Sciences, Universidad Andres Bello, Santiago 7591538, Santiago, Chile
| | - Carlos Zaror
- Pediatric Dentist and Orthodontic, Universidad de La Frontera, Temuco, Chile
| | - Pamela Seron
- CIGES, Universidad de La Frontera, Temuco, Chile
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Suk Chang J, Ko H, Hee Im S, Sung Kim J, Kyung Byun H, Bae Kim Y, Jung W, Park G, Sun Lee H, Sung W, Olson R, Hong CS, Kim K. Incorporating axillary-lateral thoracic vessel juncture dosimetric variables improves model for predicting lymphedema in patients with breast cancer: A validation analysis. Clin Transl Radiat Oncol 2023; 41:100629. [PMID: 37131951 PMCID: PMC10149196 DOI: 10.1016/j.ctro.2023.100629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/13/2023] [Accepted: 04/17/2023] [Indexed: 05/04/2023] Open
Abstract
Background A relationship between the axillary-lateral thoracic vessel juncture (ALTJ) dose and lymphedema rate has been reported in patients with breast cancer. The purpose of this study was to validate this relationship and explore whether incorporation of the ALTJ dose-distribution parameters improves the prediction model's accuracy. Methods A total of 1,449 women with breast cancer who were treated with multimodal therapies from two institutions were analyzed. We categorized regional nodal irradiation (RNI) as limited RNI, which excluded level I/II, vs extensive RNI, which included level I/II. The ALTJ was delineated retrospectively, and dosimetric and clinical parameters were analyzed to determine the accuracy of predicting the development of lymphedema. Decision tree and random forest algorithms were used to construct the prediction models of the obtained dataset. We used Harrell's C-index to assess discrimination. Results The median follow-up time was 77.3 months, and the 5-year lymphedema rate was 6.8 %. According to the decision tree analysis, the lowest lymphedema rate (5-year, 1.2 %) was observed in patients with ≤ six removed lymph nodes and ≤ 66 % ALTJ V35Gy. The highest lymphedema rate was observed in patients with > 15 removed lymph nodes and an ALTJ maximum dose (Dmax) of > 53 Gy (5-year, 71.4 %). Patients with > 15 removed lymph nodes and an ALTJ Dmax ≤ 53 Gy had the second highest rate (5-year, 21.5 %). All other patients had relatively minor differences, with a rate of 9.5 % at 5 years. Random forest analysis revealed that the model's C-index increased from 0.84 to 0.90 if dosimetric parameters were included instead of RNI (P <.001). Conclusion The prognostic value of ALTJ for lymphedema was externally validated. The estimation of lymphedema risk based on individual dose-distribution parameters of the ALTJ seemed more reliable than that based on the conventional RNI field design.
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Affiliation(s)
- Jee Suk Chang
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Republic of Korea
- Corresponding authors.
| | - Heejoo Ko
- College of Medicine, The Catholic University of Korea, Republic of Korea
| | - Sang Hee Im
- Department and Research Institute of Rehabilitation Medicine, Severance Hospital, Yonsei University College of Medicine, Republic of Korea
| | - Jin Sung Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Republic of Korea
| | - Hwa Kyung Byun
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Republic of Korea
| | - Yong Bae Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Republic of Korea
| | - Wonguen Jung
- Department of Radiation Oncology, Ewha Womans University College of Medicine, Republic of Korea
| | - Goeun Park
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Republic of Korea
| | - Hye Sun Lee
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Republic of Korea
| | - Wonmo Sung
- Department of Biomedical Engineering and of Biomedicine & Health Sciences, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Robert Olson
- British Columbia Cancer Agency - Centre for the North, Prince George, BC, Canada
| | - Chae-Seon Hong
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Republic of Korea
| | - Kyubo Kim
- Department of Radiation Oncology, Ewha Womans University College of Medicine, Republic of Korea
- Corresponding authors.
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Dixon AW, Richardson SP, Suami H, Babarenda Gamage TP, Nielsen PMF, Reynolds HM. Toward Development of a Portable System for 3D Fluorescence Lymphography. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2023; 2023:1-4. [PMID: 38082759 DOI: 10.1109/embc40787.2023.10341111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Lymphoedema is a debilitating disease that results in chronic swelling of a body region due to a dysfunctional lymphatic system. Since a cure is yet to be identified for this disease, management is currently the best option for preventing disease progression and improving patient outcomes. Fluorescence lymphography is a popular approach for mapping the lymphatic vessels to provide information about the underlying lymphatic dysfunction. However, current clinical fluorescence lymphography tools do not enable the creation of comprehensive 3D maps of lymphatics throughout affected limbs. This work presents the development toward multi-camera 3D reconstruction with fluorescence imaging to overcome the current limitations in clinical tools. Pilot studies have been performed that identify suitable instrumentation for this multi-camera approach and techniques for creating a 3D fluorescence lymphography device are discussed.Clinical Relevance- This paper presents development toward new low-cost and portable clinical tools for lymphoedema diagnosis and to facilitate personalised treatment and self-management of this disease.
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Sui YF, Tong LQ, Lin XF, Wu HX, Shi JQ, Wang SS, Tang BH, Song ZH. Revitalizing quality of life: a case report on the beneficial impact of comprehensive rehabilitation therapy in treating upper-limb lymphedema following breast cancer surgery. Front Oncol 2023; 13:1046003. [PMID: 37397387 PMCID: PMC10313100 DOI: 10.3389/fonc.2023.1046003] [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: 09/16/2022] [Accepted: 05/23/2023] [Indexed: 07/04/2023] Open
Abstract
Objective To underscore the paramount significance of incorporating comprehensive rehabilitation therapy as a crucial aspect of managing lymphedema caused by breast cancer surgery, and to illuminate our first-hand experience and insights gained in utilizing this approach. Methods We present a case report of a breast cancer survivor who had been suffering from persistent left upper-limb edema for over 15 years, who was effectively treated with a combination of conventional rehabilitation (seven-step decongestion therapy) and a comprehensive rehabilitation program (seven-step decongestion therapy, along with core and respiratory function training, as well as functional brace wearing). The efficacy of the rehabilitation therapy was evaluated through a comprehensive assessment. Results Although the patient underwent the conventional rehabilitation program for one month, only limited improvement was observed. However, after an additional month of comprehensive rehabilitation treatment, the patient exhibited significant improvement in both lymphedema and the overall function of the left upper limb. The patient's progress was quantified by measuring the reduction in arm circumference, which demonstrated a notable decrease. Furthermore, improvements in joint range of motion were observed, with forward flexion of the shoulder enhancing by 10°, forward flexion improving by 15°, and elbow flexion increasing by 10°. In addition, manual muscular strength tests revealed an increase in strength from Grade 4 to Grade 5. The patient's quality of life was also significantly improved, as evidenced by the increase in the Activities of Daily Living score from 95 to 100 points, the increase in the the Functional Assessment of Cancer Therapy: Breast score from 53 to 79 points, and the decrease in the Kessler Psychological Distress Scale score from 24 to 17 points. Conclusion While seven-step decongestion therapy has been shown to be effective in reducing upper-limb lymphedema caused by breast cancer surgery, it has limitations in treating more chronic cases of the condition. However, when combined with core and respiratory function training and functional brace wearing, seven-step decongestion therapy has been shown to be even more effective in reducing lymphedema and improving limb function, ultimately leading to significant improvements in quality of life.
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Affiliation(s)
- Yan-Fang Sui
- Department of Rehabilitation Medicine, Affiliated Haikou Hospital of Xiangya Medical College, Central South University, Haikou, China
| | - Lang-Qian Tong
- Department of Nuclear Medicine, Affiliated Haikou Hospital of Xiangya Medical College, Central South University, Haikou, China
| | - Xia-Fei Lin
- Department of Rehabilitation Medicine, Affiliated Haikou Hospital of Xiangya Medical College, Central South University, Haikou, China
| | - Hai-Xia Wu
- Department of Rehabilitation Medicine, Affiliated Haikou Hospital of Xiangya Medical College, Central South University, Haikou, China
| | - Jing-Qin Shi
- Department of Rehabilitation Medicine, Affiliated Haikou Hospital of Xiangya Medical College, Central South University, Haikou, China
| | - Shan-Shan Wang
- Department of Rehabilitation Medicine, Affiliated Haikou Hospital of Xiangya Medical College, Central South University, Haikou, China
| | - Bu-He Tang
- Department of Rehabilitation Medicine, Hainan Sino-german orthopaedic Hospital, Haikou, China
| | - Zhen-Hua Song
- Department of Rehabilitation Medicine, Affiliated Haikou Hospital of Xiangya Medical College, Central South University, Haikou, China
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Xiong Q, Luo F, Zhan J, Qiao J, Duan Y, Huang J, Li R, Liu H, Jin P. Effect of manual lymphatic drainage combined with targeted rehabilitation therapies on the recovery of upper limb function in patients with modified radical mastectomy: A randomized controlled trial. Turk J Phys Med Rehabil 2023; 69:161-170. [PMID: 37671384 PMCID: PMC10475909 DOI: 10.5606/tftrd.2023.11221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 10/14/2022] [Indexed: 09/07/2023] Open
Abstract
Objectives This study aimed to evaluate the effect of manual lymphatic drainage (MLD) combined with targeted rehabilitation therapies on the recovery of upper limb function in patients with breast cancer after modified radical mastectomy. Patients and methods In the randomized controlled study conducted between October 2019 and June 2020, 104 eligible breast cancer patients who underwent modified radical mastectomy were randomly divided into two groups. The routine functional exercise group (Group RF) received regular functional exercise guidance. In addition, the MLD combined with targeted rehabilitation therapies group (Group MLDT) received MLD, targeted rehabilitation therapies, and regular functional exercise guidance. The primary endpoints were shoulder range of motion, arm circumference and the incidence of axillary web syndrome (AWS). The secondary endpoints included the duration of axillary drainage, the duration of chest wall drainage, and complications. Results One hundred participants (mean age: 51.9±8.0 years; range, 28 to 72 years) were included in the final analysis as four patients could not complete the study. A significant improvement in shoulder range of motion was observed in Group MLDT compared to Group RF (p<0.05). Additionally, in Group MLDT, the duration of chest wall drainage was reduced (p=0.037). The frequency of AWS in Group RF was twice that in Group MLDT (p=0.061), but there was no significant difference in arm circumference (p>0.05) or the duration of axillary drainage (p=0.519). Regarding complications, there was one case of necrosis in the MLDT group and four cases in the RF group, including wound infection and seroma. Conclusion Manual lymphatic drainage combined with targeted rehabilitation therapies is an effective strategy to improve shoulder function, shorten the duration of chest wall drainage, reduce complications, and partly lower the incidence of AWS.
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Affiliation(s)
- Qian Xiong
- Department of Breast Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Feng Luo
- Department of Breast Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jing Zhan
- Department of Breast Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jia Qiao
- Sun Yat-Sen University, Guangdong, China
| | - Yi Duan
- Department of Breast Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jie Huang
- Department of Breast Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Rong Li
- Department of Breast Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hong Liu
- Department of Breast Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Pengjuan Jin
- Department of Breast Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Chen J, Guo Z, Luo X, Zhang Y, Zhang X, Li M, Xiong C, Zhao M, Yan J. Longitudinal trajectories of illness perception regarding breast cancer-related lymphedema among women with breast cancer. J Psychosom Res 2023; 170:111344. [PMID: 37178472 DOI: 10.1016/j.jpsychores.2023.111344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 03/19/2023] [Accepted: 04/29/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVE To identify longitudinal trajectories of illness perception (IP) regarding breast cancer-related lymphedema (BCRL) in the first six months after surgery among women with breast cancer and to explore the predictive effects of demographics and clinical factors on IP trajectories. METHODS From August 2019 to August 2021, a total of 352 patients participated in this study, 328 of whom were included in the data analysis. Demographic and clinical characteristics were collected at baseline (1-3 days after surgery). The BCRL-specific revised illness perception questionnaire was used to measure IP regarding BCRL at baseline and 1 month, 3 months and 6 months post-surgery. A multilevel model was conducted to analyze the data. RESULTS Over the first six months post-surgery, the "timeline acute/chronic" and "illness coherence" dimensions showed positive growth trajectories; the "personal control" and "treatment control" dimensions presented negative growth trajectories; and the trajectories of identity, consequences, cyclicality and emotional influence perceptions regarding BCRL showed no significant changes. Age, education level, marital status, employment status, family monthly income per person, cancer stage and status of removed lymph nodes were indicated to be predictive factors of IP trajectories. CONCLUSIONS The present study determined significant changes over the first six months post-surgery in four IP dimensions and predictive effects of some demographics and clinical details on IP trajectories. These findings may help healthcare providers know more about the dynamic characteristics of IPs regarding BCRL in patients with breast cancer and assist them in identifying patients with a tendency toward improper IP regarding BCRL.
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Affiliation(s)
- Jing Chen
- School of Nursing, Sun Yat-Sen University, No. 74, Zhongshan II Road, Guangzhou, Guangdong Province, China
| | - Zijun Guo
- School of Nursing, Sun Yat-Sen University, No. 74, Zhongshan II Road, Guangzhou, Guangdong Province, China
| | - Xia Luo
- School of Nursing, Sun Yat-Sen University, No. 74, Zhongshan II Road, Guangzhou, Guangdong Province, China
| | - Yue Zhang
- School of Nursing, Sun Yat-Sen University, No. 74, Zhongshan II Road, Guangzhou, Guangdong Province, China
| | - Xiaomin Zhang
- School of Nursing, Sun Yat-Sen University, No. 74, Zhongshan II Road, Guangzhou, Guangdong Province, China
| | - Mingfang Li
- School of Nursing, Sun Yat-Sen University, No. 74, Zhongshan II Road, Guangzhou, Guangdong Province, China
| | - Chenxia Xiong
- School of Nursing, Sun Yat-Sen University, No. 74, Zhongshan II Road, Guangzhou, Guangdong Province, China
| | - Meng Zhao
- School of Nursing, Sun Yat-Sen University, No. 74, Zhongshan II Road, Guangzhou, Guangdong Province, China
| | - Jun Yan
- School of Nursing, Sun Yat-Sen University, No. 74, Zhongshan II Road, Guangzhou, Guangdong Province, China.
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Donahue PMC, MacKenzie A, Filipovic A, Koelmeyer L. Advances in the prevention and treatment of breast cancer-related lymphedema. Breast Cancer Res Treat 2023; 200:1-14. [PMID: 37103598 DOI: 10.1007/s10549-023-06947-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 04/06/2023] [Indexed: 04/28/2023]
Abstract
PURPOSE Breast cancer-related lymphedema (BCRL) represents a lifelong risk for breast cancer survivors and once acquired becomes a lifelong burden. This review summarizes current BCRL prevention and treatment strategies. FINDINGS Risk factors for BCRL have been extensively studied and their identification has affected breast cancer treatment practice, with sentinel lymph node removal now standard of care for patients with early stage breast cancer without sentinel lymph node metastases. Early surveillance and timely management aim to reduce BCRL incidence and progression, and are further facilitated by patient education, which many breast cancer survivors report not having adequately received. Surgical approaches to BCRL prevention include axillary reverse mapping, lymphatic microsurgical preventative healing (LYMPHA) and Simplified LYMPHA (SLYMPHA). Complete decongestive therapy (CDT) remains the standard of care for patients with BCRL. Among CDT components, facilitating manual lymphatic drainage (MLD) using indocyanine green fluorescence lymphography has been proposed. Intermittent pneumatic compression, nonpneumatic active compression devices, and low-level laser therapy appear promising in lymphedema management. Reconstructive microsurgical techniques such as lymphovenous anastomosis and vascular lymph node transfer are growing surgical considerations for patients as well as liposuction-based procedures for addressing fatty fibrosis formation from chronic lymphedema. Long-term self-management adherence remains problematic, and lack of diagnosis and measurement consensus precludes a comparison of outcomes. Currently, no pharmacological approaches have proven successful. CONCLUSION Progress in prevention and treatment of BCRL continues, requiring advances in early diagnosis, patient education, expert consensus and novel treatments designed for lymphatic rehabilitation following insults.
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Affiliation(s)
- Paula M C Donahue
- Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, 2201 21St Children's Way, Suite 1218, Nashville, TN, 37212, USA.
- Dayani Center for Health and Wellness, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Adrien MacKenzie
- Osher Center for Integrative Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Louise Koelmeyer
- Faculty of Medicine, Health, and Human Sciences, Australian Lymphoedema Education, Research, and Treatment (ALERT), Macquarie University, Sydney, Australia
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Liu X, Sun K, Yang H, Xia L, Lu K, Meng X, Li Y. Risk factors for the development of severe breast cancer-related lymphedema: a retrospective cohort study. BMC Cancer 2023; 23:361. [PMID: 37081431 PMCID: PMC10116791 DOI: 10.1186/s12885-023-10814-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 04/06/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND Severe lymphedema presents a challenge in terms of treatment due to the significant formation of scar tissue that accompanies it. The aim of this study was to identify intraoperative and preoperative risk factors of severe lymphedema and to develop a nomogram for estimating the risk of severe lymphedema within 3 years of surgery. METHOD Data was collected from a retrospective cohort of 326 patients with BCRL at the Zhejiang Cancer Hospital from November 2015 to November 2018. Univariate and multivariate logistic regression analysis was conducted to identify predictive indicators of severe lymphedema. A nomogram was developed to further improve the clinical applicability. RESULTS In the retrospective cohort, the ratio of severe/non-severe lymphedema within 3 years of surgery was 1:3. Independent risk factors for severe lymphedema were determined to be age, positive lymph nodes, interpectoral (Rotter's) lymph nodes (IPNs) dissection, and educational level. IPNs dissection was found to contribute greatly to the development of severe lymphedema with a higher odds ratio (7.76; 95% CI: 3.87-15.54) than other risk factors. A nomogram was developed by integrating age, positive lymph nodes, IPNs dissection, and educational level, which yielded a C-index of 0.810 and 0.681 in the training and validation cohort, respectively. This suggested a moderate performance of the nomogram in predicting the risk of severe lymphedema within 3 years of surgery. The cut-off values of the low-, medium- and high-risk probabilities were 0.0876 and 0.3498, and the severe lymphedema exhibited a significantly higher risk probability as compared with the non-severe lymphedema. CONCLUSION This study identified the risk factors of severe lymphedema and highlighted the substantial contribution of IPNs dissection to the severity of lymphedema.
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Affiliation(s)
- Xiaozhen Liu
- General Surgery, Cancer center, Department of Breast Surgery, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China
| | - Kewang Sun
- General Surgery, Cancer center, Department of Breast Surgery, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China
| | - Hongjian Yang
- Department of Breast Surgery, Institute of Cancer Research and Basic Medical Sciences of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, 310022, Zhejiang, China
| | - Lingli Xia
- Department of Breast Surgery, Institute of Cancer Research and Basic Medical Sciences of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, 310022, Zhejiang, China
| | - Kefeng Lu
- Department of outpatient service, Institute of Cancer Research and Basic Medical Sciences of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, 310022, Zhejiang, China
- Cancer center, Department of Ultrasound Medicine, Affiliated People's Hospital, Zhejiang Provincial People's Hospital, Hangzhou Medical college), Hangzhou, 310014, Zhejiang, China
| | - Xuli Meng
- General Surgery, Cancer center, Department of Breast Surgery, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China
| | - Yongfeng Li
- General Surgery, Cancer center, Department of Breast Surgery, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China.
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Wang L, Chen H, Li Y, Wang H, Liu N, Yu M, Shang S. Body mass index increases the risk of breast cancer-related lymphedema at 6-18 months after surgery: a retrospective study. Support Care Cancer 2023; 31:278. [PMID: 37074508 DOI: 10.1007/s00520-023-07721-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 03/31/2023] [Indexed: 04/20/2023]
Abstract
PURPOSE Breast cancer-related lymphedema (BCRL) is an incurable complication occurring after breast cancer treatment. The influence of obesity/overweight on the development of BCRL at different points after surgery was seldom verified. We aimed to determine the cut-off BMI/weight value associated with an increased risk of BCRL at different postoperative time in Chinese breast cancer survivors. METHODS Patients who underwent breast surgery plus axillary lymph node dissection (ALND) were retrospectively evaluated. Disease and treatment characteristics of participants were collected. BCRL was diagnosed by circumference measurements. Univariate and multivariable logistic regression was used to assess the relationship of lymphedema risk with BMI/weight and other disease- and treatment-related factors. RESULTS 518 patients were included. Lymphedema occurred more frequently among breast cancer patients with preoperative BMI ≥ 25 kg/m2 (37.88%) than among those with preoperative BMI < 25 kg/m2(23.32%), with significant differences at 6-12 and 12-18 months after surgery (χ2 = 23.183, P = 0.000; χ2 = 5.279, P = 0.022). By multivariable logistics analysis, preoperative BMI ≥ 30 kg/m2 presented a significantly greater risk of lymphedema than a preoperative BMI < 25 kg/m2 (OR [95% CI] = 2.928 [1.565, 5.480]). Other factors, including radiation (breast/chest wall + axilla vs. none: OR [95% CI] = 3.723[2.271-6.104]), was an independent risk factor for lymphedema. CONCLUSIONS Preoperative obesity was an independent risk factor for BCRL in Chinese breast cancer survivors, and a preoperative BMI ≥ 25 kg/m2 indicated greater likelihood of lymphedema development within 6-18 months postoperatively.
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Affiliation(s)
- Ling Wang
- School of Nursing, Wannan Medical College, Wuhu, 241002, China
- School of Nursing, Peking University, Haidian District, 38 Xueyuan Road, Beijing, 100191, China
| | - Hongbo Chen
- School of Nursing, Peking University, Haidian District, 38 Xueyuan Road, Beijing, 100191, China
| | - Yuanzhen Li
- School of Nursing, Wannan Medical College, Wuhu, 241002, China
| | - Huixue Wang
- School of Nursing, Wannan Medical College, Wuhu, 241002, China
| | - Ning Liu
- School of Nursing, Wannan Medical College, Wuhu, 241002, China
| | - Miao Yu
- School of Nursing, Wannan Medical College, Wuhu, 241002, China
| | - Shaomei Shang
- School of Nursing, Peking University, Haidian District, 38 Xueyuan Road, Beijing, 100191, China.
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Shen A, Lu Q, Zhang L, Bian J, Zhu F, Zhang Z, Qiang W. Risk factors of breast cancer-related lymphoedema: protocol of an umbrella review. BMJ Open 2023; 13:e070907. [PMID: 37045580 PMCID: PMC10106017 DOI: 10.1136/bmjopen-2022-070907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2023] Open
Abstract
INTRODUCTION Breast cancer-related lymphoedema (BCRL) is a progressive and debilitating complication post-breast cancer treatment. Identifying potential risk factors facilitates the prevention and management of BCRL. Multiple systematic reviews have been conducted to address the variables correlated with the occurrence of BCRL. This study aims to identify and examine factors predicting the development of BCRL, to clarify the predicting mechanism of these factors, as well to determine the credibility of risk factors for BCRL. METHODS AND ANALYSIS This umbrella review will be conducted with the methodological guidance of the Joanna Briggs Institute and the Cochrane handbook. A comprehensive systematic search will be performed in ten databases: PubMed, Embase, CINAHL, Web of Science, Scopus, CNKI, SinoMed, Wangfang database, the JBI Database of Systematic Reviews, Cochrane Database of Systematic Reviews. The search for unpublished studies will include ProQuest and the PROSPERO register. Reference lists will also be hand searched. Two reviewers will independently screen the studies, extract data and assess the methodological quality using the Methodological Quality of Systematic Reviews-2 and the Risk of Bias in Systematic Reviews. The degree of overlap between included reviews will be assessed by calculating the Corrected Covered Area. The credibility of the associations between risk factors and lymphoedema will be graded into four classes: convincing, highly suggestive, suggestive and weak, referring to the classification system of recent umbrella reviews. A descriptive, narrative synthesis and suggestions for clinical practice and future research will be made based on included systematic reviews, considering the quality of the evidence. ETHICS AND DISSEMINATION Ethical approval is not required for this umbrella review. We will seek to submit the results for publication in a peer-reviewed journal or present it at conferences. PROSPERO REGISTRATION NUMBER CRD42022375710.
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Affiliation(s)
- Aomei Shen
- Department of Nursing, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- Division of Medical & Surgical Nursing, Peking University School of Nursing, Beijing, China
- Health Science Centre for Evidence-Based Nursing: A Joanna Briggs Institute Affiliated Group, Peking University School of Nursing, Beijing, China
| | - Qian Lu
- Division of Medical & Surgical Nursing, Peking University School of Nursing, Beijing, China
- Health Science Centre for Evidence-Based Nursing: A Joanna Briggs Institute Affiliated Group, Peking University School of Nursing, Beijing, China
| | - Liyuan Zhang
- Tianjin Medical University School of Nursing, Tianjin, China
| | - Jingru Bian
- Tianjin Medical University School of Nursing, Tianjin, China
| | - Fei Zhu
- Hebei University School of Nursing, Baoding, Hebei, China
| | - Zijuan Zhang
- Division of Medical & Surgical Nursing, Peking University School of Nursing, Beijing, China
- Health Science Centre for Evidence-Based Nursing: A Joanna Briggs Institute Affiliated Group, Peking University School of Nursing, Beijing, China
| | - Wanmin Qiang
- Department of Nursing, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
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Shen A, Wei X, Zhu F, Sun M, Ke S, Qiang W, Lu Q. Risk prediction models for breast cancer-related lymphedema: A systematic review and meta-analysis. Eur J Oncol Nurs 2023; 64:102326. [PMID: 37137249 DOI: 10.1016/j.ejon.2023.102326] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/10/2023] [Accepted: 03/18/2023] [Indexed: 03/31/2023]
Abstract
PURPOSE To review and critically evaluate currently available risk prediction models for breast cancer-related lymphedema (BCRL). METHODS PubMed, Embase, CINAHL, Scopus, Web of Science, the Cochrane Library, CNKI, SinoMed, WangFang Data, VIP Database were searched from inception to April 1, 2022, and updated on November 8, 2022. Study selection, data extraction and quality assessment were conducted by two independent reviewers. The Prediction Model Risk of Bias Assessment Tool was used to assess the risk of bias and applicability. Meta-analysis of AUC values of model external validations was performed using Stata 17.0. RESULTS Twenty-one studies were included, reporting twenty-two prediction models, with the AUC or C-index ranging from 0.601 to 0.965. Only two models were externally validated, with the pooled AUC of 0.70 (n = 3, 95%CI: 0.67 to 0.74), and 0.80 (n = 3, 95%CI: 0.75 to 0.86), respectively. Most models were developed using classical regression methods, with two studies using machine learning. Predictors most frequently used in included models were radiotherapy, body mass index before surgery, number of lymph nodes dissected, and chemotherapy. All studies were judged as high overall risk of bias and poorly reported. CONCLUSIONS Current models for predicting BCRL showed moderate to good predictive performance. However, all models were at high risk of bias and poorly reported, and their performance is probably optimistic. None of these models is suitable for recommendation in clinical practice. Future research should focus on validating, optimizing, or developing new models in well-designed and reported studies, following the methodology guidance and reporting guidelines.
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42
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Evidence-Based Guidance for Breast Cancer Survivorship. Hematol Oncol Clin North Am 2023; 37:225-243. [PMID: 36435612 DOI: 10.1016/j.hoc.2022.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Breast cancer survivorship care includes management of lingering physical symptoms, supports to address the emotional toll exacted by a cancer diagnosis and cancer therapies, monitoring and optimization of cardiac and bone health, general wellness promotion, reproductive health care, surveillance for cancer recurrence, care coordination, and efforts to mitigate health disparities.
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Nascimben M, Lippi L, de Sire A, Invernizzi M, Rimondini L. Algorithm-Based Risk Identification in Patients with Breast Cancer-Related Lymphedema: A Cross-Sectional Study. Cancers (Basel) 2023; 15:cancers15020336. [PMID: 36672283 PMCID: PMC9856619 DOI: 10.3390/cancers15020336] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 12/27/2022] [Indexed: 01/06/2023] Open
Abstract
Background: Breast cancer-related lymphedema (BCRL) could be one consequence of breast cancer (BC). Although several risk factors have been identified, a predictive algorithm still needs to be made available to determine the patient's risk from an ensemble of clinical variables. Therefore, this study aimed to characterize the risk of BCRL by investigating the characteristics of autogenerated clusters of patients. Methods: The dataset under analysis was a multi-centric data collection of twenty-three clinical features from patients undergoing axillary dissection for BC and presenting BCRL or not. The patients' variables were initially analyzed separately in two low-dimensional embeddings. Afterward, the two models were merged in a bi-dimensional prognostic map, with patients categorized into three clusters using a Gaussian mixture model. Results: The prognostic map represented the medical records of 294 women (mean age: 59.823±12.879 years) grouped into three clusters with a different proportion of subjects affected by BCRL (probability that a patient with BCRL belonged to Cluster A: 5.71%; Cluster B: 71.42%; Cluster C: 22.86%). The investigation evaluated intra- and inter-cluster factors and identified a subset of clinical variables meaningful in determining cluster membership and significantly associated with BCRL biological hazard. Conclusions: The results of this study provide potential insight for precise risk assessment of patients affected by BCRL, with implications in prevention strategies, for instance, focusing the resources on identifying patients at higher risk.
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Affiliation(s)
- Mauro Nascimben
- Center for Translational Research on Autoimmune and Allergic Diseases-CAAD, Department of Health Sciences, Università del Piemonte Orientale “A. Avogadro”, 28100 Novara, Italy
- Enginsoft SpA, 35129 Padua, Italy
- Correspondence:
| | - Lorenzo Lippi
- Physical and Rehabilitative Medicine, Department of Health Sciences, Università del Piemonte Orientale “A. Avogadro”, 28100 Novara, Italy
- Infrastruttura Ricerca Formazione Innovazione (IRFI), Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy
| | - Alessandro de Sire
- Physical and Rehabilitative Medicine Unit, Department of Medical and Surgical Sciences, University of Catanzaro “Magna Græcia”, 88100 Catanzaro, Italy
| | - Marco Invernizzi
- Physical and Rehabilitative Medicine, Department of Health Sciences, Università del Piemonte Orientale “A. Avogadro”, 28100 Novara, Italy
- Infrastruttura Ricerca Formazione Innovazione (IRFI), Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy
| | - Lia Rimondini
- Center for Translational Research on Autoimmune and Allergic Diseases-CAAD, Department of Health Sciences, Università del Piemonte Orientale “A. Avogadro”, 28100 Novara, Italy
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What do we know about treating breast-cancer-related lymphedema? Review of the current knowledge about therapeutic options. Breast Cancer 2023; 30:187-199. [PMID: 36571707 PMCID: PMC9950281 DOI: 10.1007/s12282-022-01428-z] [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: 08/01/2022] [Accepted: 12/16/2022] [Indexed: 12/27/2022]
Abstract
Breast-cancer-related lymphedema (BCRL) is a common consequence of oncological treatment. Its management is a complicated, chronic, and arduous process. Therapeutic options can be divided on non-surgical and surgical methods, although there is still no clear consensus about their effectiveness in preventing or stopping the disease. That brings problems in everyday practice, as there are no guidelines about proper time for starting therapy and no agreement about which management will be beneficial for each patient. The aim of this review is to summarize current knowledge about possible treatment choices, non-surgical so as surgical, indicate knowledge gaps, and try to direct pathways for future studies.
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Jha CK, Sinha U, Sinha M, Singh PK. Breast carcinoma presenting with upper limb lymphedema - A rare case. Breast Dis 2023; 42:395-399. [PMID: 38108339 DOI: 10.3233/bd-230022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
Lymphedema (LE) in a breast cancer patient usually results from axillary lymph node dissection, sentinel lymph node biopsy, and/or axillary radiotherapy. Although lymphatic obstruction and consequent LE can occur due to axillary lymph node involvement, such presentation in breast cancer patients has rarely been reported. This report describes the case of a 50-year-old lady with right breast carcinoma who presented with right upper limb lymphedema. Surprisingly, she did not have any bulky axillary lymphadenopathy that could have accounted for lymphedema of the upper limb, but a suspicious breast mass was present on clinical examination. Diagnosis of breast cancer on clinical examination can be challenging in such patients due to breast edema and careful imaging of the breast and axilla with appropriate imaging tools (mammogram, ultrasound, MRI, PET mammography) should be resorted to before excluding malignancy. Lymphoscintigraphy confirmed the findings of lymphedema in the right upper limb and revealed uptake in the epitrochlear lymph nodes of the contralateral limb suggesting that she might had pre-existing widespread "subclinical lymphedema" which presented as "clinical lymphedema" in right upper limb after axillary lymph node/lymphatic involvement by right breast carcinoma.
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Affiliation(s)
- Chandan Kumar Jha
- Department of General Surgery, All India Institute of Medical Sciences, Patna, India
| | - Upasna Sinha
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Patna, India
| | - Mainak Sinha
- Department of General Surgery, All India Institute of Medical Sciences, Patna, India
| | - Prashant Kumar Singh
- Department of General Surgery, All India Institute of Medical Sciences, Patna, India
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Li MM, Wu PP, Qiang WM, Li JQ, Zhu MY, Yang XL, Wang Y. Development and validation of a risk prediction model for breast cancer-related lymphedema in postoperative patients with breast cancer. Eur J Oncol Nurs 2022; 63:102258. [PMID: 36821887 DOI: 10.1016/j.ejon.2022.102258] [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: 08/26/2022] [Revised: 12/05/2022] [Accepted: 12/14/2022] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Breast cancer-related lymphedema (BCRL) is a common post-operative complication in patients with breast cancer. Here, we sought to develop and validate a predictive model of BCRL in Chinese patients with breast cancer. METHODS Clinical and demographic data on patients with breast cancer were collected between 2016 and 2021 at a Cancer Hospital in China. A nomogram for predicting the risk of lymphedema in postoperative patients with breast cancer was constructed and verified using R 3.5.2 software. Model performance was evaluated using area under the ROC curve (AUC) and goodness-of-fit statistics, and the model was internally validated. RESULTS A total of 1732 postoperative patients with breast cancer, comprising 1212 and 520 patients in the development and validation groups, respectively, were included. Of these 438 (25.39%) developed lymphedema. Significant predictors identified in the predictive model were time since breast cancer surgery, level of lymph node dissection, number of lymph nodes dissected, radiotherapy, and postoperative body mass index. At the 31.9% optimal cut-off the model had AUC values of 0.728 and 0.710 in the development and validation groups, respectively. Calibration plots showed a good match between predicted and observed rates. In decision curve analysis, the net benefit of the model was better between threshold probabilities of 10%-80%. CONCLUSION The model has good discrimination and accuracy for lymphedema risk assessment, which can provide a reference for individualized clinical prediction of the risk of BCRL. Multicenter prospective trials are required to verify the predictive value of the model.
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Affiliation(s)
- Miao-Miao Li
- Breast Oncology Department, Tianjin Medical University Cancer Institute & Hospital, Tianjin, 300060, China.
| | - Pei-Pei Wu
- Nursing Department, Tianjin Medical University Cancer Institute & Hospital, Tianjin, 300060, China.
| | - Wan-Min Qiang
- Nursing Department, Tianjin Medical University Cancer Institute & Hospital, Tianjin, 300060, China.
| | - Jia-Qian Li
- Breast Oncology Department, Tianjin Medical University Cancer Institute & Hospital, Tianjin, 300060, China.
| | - Ming-Yu Zhu
- Breast Oncology Department, Tianjin Medical University Cancer Institute & Hospital, Tianjin, 300060, China.
| | - Xiao-Lin Yang
- Breast Oncology Department, Tianjin Medical University Cancer Institute & Hospital, Tianjin, 300060, China.
| | - Ying Wang
- Nursing Department, Tianjin Medical University Cancer Institute & Hospital, Tianjin, 300060, China.
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Gennaro M, Maccauro M, Mariani L, Listorti C, Sigari C, De Vivo A, Chisari M, Maugeri I, Lorenzoni A, Aliberti G, Scaperrotta GP, Caraceni A, Pruneri G, Folli S. Occurrence of breast-cancer-related lymphedema after reverse lymphatic mapping and selective axillary dissection versus standard surgical treatment of axilla: A two-arm randomized clinical trial. Cancer 2022; 128:4185-4193. [PMID: 36259883 PMCID: PMC10092060 DOI: 10.1002/cncr.34498] [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: 04/20/2022] [Revised: 08/18/2022] [Accepted: 08/22/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND The need for axillary dissection (AD) is declining, but it is still essential for many patients with nodal involvement who risk developing breast-cancer-related lymphedema (BCRL) with lifelong consequences. Previous nonrandomized studies found axillary reverse mapping and selective axillary dissection (ARM-SAD) a safe and feasible way to preserve the arm's lymphatic drainage. METHODS The present two-arm prospective randomized clinical trial was held at a single comprehensive cancer center to ascertain whether ARM-SAD can reduce the risk of BCRL, compared with standard AD, in patients with node-positive breast cancer. Whatever the type of breast surgery or adjuvant treatments planned, 130 patients with nodal involvement met our inclusion criteria: 65 were randomized for AD and 65 for ARM-SAD. Twelve months after surgery, a physiatrist assessed patients for BCRL and calculated the excess volume of the operated arm. Lymphoscintigraphy was used to assess drainage impairment. Self-reports of any impairment were also recorded. RESULTS The difference in the incidence of BCRL between the two groups was 21% (95% CI, 3-37; p = .03). A significantly lower rate of BCRL after ARM-SAD was confirmed by a multimodal analysis that included the physiatrist's findings, excess arm volume, and lymphoscintigraphic findings, but this was not matched by a significant difference in patients' self-reports. CONCLUSIONS Our findings encourage a change of surgical approach when AD is still warranted. ARM-SAD may be an alternative to standard AD to reduce the treatment-related morbidity.
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Affiliation(s)
| | - Marco Maccauro
- Nuclear Medicine Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Luigi Mariani
- Department of Clinical Epidemiology and Trials Organization, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Chiara Listorti
- Breast Surgery Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Carmela Sigari
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Annarita De Vivo
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Marco Chisari
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Ilaria Maugeri
- Breast Surgery Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Alice Lorenzoni
- Nuclear Medicine Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Gianluca Aliberti
- Nuclear Medicine Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Gianfranco P Scaperrotta
- Breast Imaging Unit, Radiology Department, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Augusto Caraceni
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Giancarlo Pruneri
- Pathology Department, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Secondo Folli
- Breast Surgery Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
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Risk factors of unilateral breast cancer-related lymphedema: an updated systematic review and meta-analysis of 84 cohort studies. Support Care Cancer 2022; 31:18. [PMID: 36513801 DOI: 10.1007/s00520-022-07508-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 12/02/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE To review and update the incidence and risk factors for breast cancer-related lymphedema based on cohort studies. METHODS The study was guided by the Joanna Briggs Institute methodology and the Cochrane handbook for systematic reviews. PubMed, EMBASE, CINAHL, Scopus, Web of Science, The Cochrane Library, CNKI, SinoMed, and Wan Fang Database were searched from inception to November 15, 2021. Cohort studies reported adjusted risk factors were selected. PRISMA guideline was followed. Study quality were evaluated using the Newcastle-Ottawa scale. Random-effects models were adopted. The robustness of pooled estimates was validated by meta-regression and subgroup analysis. Lymphedema incidence and adjusted risk factors in the multivariable analyses with hazard / odds ratios and 95% CIs were recorded. RESULTS Eighty-four cohort studies involving 58,358 breast cancer patients were included. The pooled incidence of lymphedema was 21.9% (95% CI, 19.8-24.0%). Fourteen factors were identified including ethnicity (black vs. white), higher body mass index, higher weight increase, hypertension, higher cancer stage (III vs. I-II), larger tumor size, mastectomy (vs. breast conservation surgery), axillary lymph nodes dissection, more lymph nodes dissected, higher level of lymph nodes dissection, chemotherapy, radiotherapy, surgery complications, and higher relative volume increase postoperatively. Additionally, breast reconstruction surgery, and adequate finance were found to play a protective role. However, other variables such as age, number of positive lymph nodes, and exercise were not correlated with risk of lymphedema. CONCLUSION Treatment-related factors still leading the development of breast cancer-related lymphedema. Other factors such as postoperative weight increase and finance status also play a part. Our findings suggest the need to shift the focus from treatment-related factors to modifiable psycho-social-behavioral factors.
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Bartels SA, Donker M, Poncet C, Sauvé N, Straver ME, van de Velde CJ, Mansel RE, Blanken C, Orzalesi L, Klinkenbijl JH, van der Mijle HC, Nieuwenhuijzen GA, Veltkamp SC, van Dalen T, Marinelli A, Rijna H, Snoj M, Bundred NJ, Merkus JW, Belkacemi Y, Petignat P, Schinagl DA, Coens C, van Tienhoven G, van Duijnhoven F, Rutgers EJ. Radiotherapy or Surgery of the Axilla After a Positive Sentinel Node in Breast Cancer: 10-Year Results of the Randomized Controlled EORTC 10981-22023 AMAROS Trial. J Clin Oncol 2022; 41:2159-2165. [PMID: 36383926 DOI: 10.1200/jco.22.01565] [Citation(s) in RCA: 93] [Impact Index Per Article: 46.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Clinical trials frequently include multiple end points that mature at different times. The initial report, typically based on the primary end point, may be published when key planned co-primary or secondary analyses are not yet available. Clinical Trial Updates provide an opportunity to disseminate additional results from studies, published in JCO or elsewhere, for which the primary end point has already been reported. PURPOSE The European Organisation for Research and Treatment of Cancer 10981-22023 AMAROS trial evaluated axillary lymph node dissection (ALND) versus axillary radiotherapy (ART) in patients with cT1-2, node-negative breast cancer and a positive sentinel node (SN) biopsy. At 5 years, both modalities showed excellent and comparable axillary control, with significantly less morbidity after ART. We now report the preplanned 10-year analysis of the axillary recurrence rate (ARR), overall survival (OS), and disease-free survival (DFS), and an updated 5-year analysis of morbidity and quality of life. METHODS In this open-label multicenter phase III noninferiority trial, 4,806 patients underwent SN biopsy; 1,425 were node-positive and randomly assigned to either ALND (n = 744) or ART (n = 681). RESULTS Per intention-to-treat analysis, 10-year ARR cumulative incidence was 0.93% (95% CI, 0.18 to 1.68; seven events) after ALND and 1.82% (95% CI, 0.74 to 2.94; 11 events) after ART (hazard ratio [HR], 1.71; 95% CI, 0.67 to 4.39). There were no differences in OS (HR, 1.17; 95% CI, 0.89 to 1.52) or DFS (HR, 1.19; 95% CI, 0.97 to 1.46). ALND was associated with a higher lymphedema rate in updated 5-year analyses (24.5% v 11.9%; P < .001). Quality-of-life scales did not differ by treatment through 5 years. Exploratory analysis showed a 10-year cumulative incidence of second primary cancers of 12.1% (95% CI, 9.6 to 14.9) after ART and 8.3% (95% CI, 6.3 to 10.7) after ALND. CONCLUSION This 10-year analysis confirms a low ARR after both ART and ALND with no difference in OS, DFS, and locoregional control. Considering less arm morbidity, ART is preferred over ALND for patients with SN-positive cT1-2 breast cancer.
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Affiliation(s)
- Sanne A.L. Bartels
- European Organisation for Research and Treatment of Cancer Headquarters, Brussels, Belgium
- Department of Surgical Oncology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Mila Donker
- Department of Surgical Oncology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Coralie Poncet
- European Organisation for Research and Treatment of Cancer Headquarters, Brussels, Belgium
| | - Nicolas Sauvé
- European Organisation for Research and Treatment of Cancer Headquarters, Brussels, Belgium
| | - Marieke E. Straver
- Department of Surgery, Haaglanden Medical Center, Den Haag, the Netherlands
| | | | - Robert E. Mansel
- Department of Surgery, Cardiff University, Cardiff, United Kingdom
| | | | | | | | | | | | - Sanne C. Veltkamp
- Department of Surgery, Amstelland Hospital, Amstelveen, the Netherlands
| | - Thijs van Dalen
- Department of Surgery, Diakonessenhuis, Utrecht, the Netherlands
| | - Andreas Marinelli
- Department of Surgery, Haaglanden Medical Center, Den Haag, the Netherlands
| | - Herman Rijna
- Department of Surgery, Spaarne Gasthuis, Haarlem, the Netherlands
| | - Marko Snoj
- Department of Surgery, Institute of Oncology, Ljubljana, Slovenia
| | - Nigel J. Bundred
- Department of Surgery, University of Manchester and Manchester University Foundation Trust, Manchester, United Kingdom
| | - Jos W.S. Merkus
- Department of Surgery, Haga Hospital, Den Haag, the Netherlands
| | - Yazid Belkacemi
- Department of Radiation Oncology, Centre Oscar Lambret, Lille, France
- AP-HP, Radiation Therapy and Breast Center of Henri Mondor, University of Paris Est Creteil (UPEC), Créteil, France
| | - Patrick Petignat
- Division of Gynecology, Geneva University Hospital, Geneva, Switzerland
| | - Dominic A.X. Schinagl
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Corneel Coens
- European Organisation for Research and Treatment of Cancer Headquarters, Brussels, Belgium
| | - Geertjan van Tienhoven
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands
| | | | - Emiel J.T. Rutgers
- Department of Surgical Oncology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
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Thalji SZ, Cortina CS, Guo MS, Kong AL. Postoperative Complications from Breast and Axillary Surgery. Surg Clin North Am 2022; 103:121-139. [DOI: 10.1016/j.suc.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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