Who Needs Level III Lymph Node Dissection in Carcinoma Breast-Study from a Tertiary Care Center

In Indian females, breast cancer is the most common cancer with a late stage of presentation leading to one-third of patients undergoing modified radical mastectomy (MRM). Our study is undertaken to find out predictors of level III axillary lymph node metastasis in breast cancer and who needs complete axillary lymph node dissection (ALND). Retrospective study of 146 patients who undergone MRM or breast-conserving surgery (BCS) with complete ALND at Kidwai Memorial Institute of Oncology was done, and data was analyzed to find out the frequency of level III lymph nodes and the demographic relation and its relation to positive lymph nodes in level I + II. Positive metastatic level III lymph node was found in 6% of patients, with the median age of the patient in our study with level III positivity was 48.5 years with 63% pathological stage II with 88% perinodal spread (PNS)- and lymphovascular invasion (LVI)-positive. Involvement of level III lymph node was associated with gross disease in level I + II lymph node having more than four lymph node-positive and with pT3 stage or more which has higher chances of level III lymph node involvement. Level III lymph node involvement, though rare in early-stage breast cancer, is associated with larger clinical and pathological sizes (T3 or more), more than 4 lymph node-positive in level I + II and with PNS and LVI. Hence, based on these results, we recommend that for inpatient with more than 5-cm tumor size and those with the gross disease in axilla, complete ALND is recommended.

Axillary Recurrence in Breast Cancer Patients After Negative Sentinel Lymph Node Biopsy: Retrospective Cohort Study From Riyadh, Saudi Arabia

Breast cancer (BC) is among the most prevalent cancers globally. For minimally invasive axillary staging in early breast cancer, sentinel lymph node biopsy (SLNB) is commonly regarded as the gold standard. Historically, axillary lymph node dissection (ALND) was used as a staging procedure, but the less morbid SLNB has now replaced it. This retrospective cohort study, undertaken with patients at King Saud University Medical City in Riyadh, Saudi Arabia, evaluates mid-term follow-up data on axillary recurrences and outcomes for breast cancer patients with negative SLNB. The results indicate that the five-year risk of developing regional recurrence following negative SLNB is 0% in breast cancer patients. The low relapse rate further contributes to the evidence base suggesting the efficacy of SLNB and the higher morbidity associated with ALND. Future researchers should conduct a nationwide and long-term follow-up study to offer additional insights into the efficacy of SLNB.

Avoiding breast cancer surgery in a select cohort of complete responders to neoadjuvant chemotherapy: The long-term outcomes

BACKGROUND

Lately, there has been a resurgence of interest in de-escalation of breast surgery in complete responders to neoadjuvant chemotherapy (NAC). Advanced cytotoxic & targeted therapies have improved tumour response.This study evaluates long-term outcomes of post-NAC breast cancer patients, in relation to their surgical management dictated by the NAC response.

MATERIALS AND METHODS

Post-NAC breast cancer patients from January 2000 to December 2010 were divided into "No surgery", "WLE" and "Mastectomy" groups. ANOVA and Kaplan-Meier statistical analyses were used to compare overall survival (OS) and disease-free-survival (DFS) in these groups.

RESULTS

This retrospective study included 121 patients with a long median follow-up of 11.5 years. At 10 years the OS was 66.10% and DFS was 59.82%. Complete NAC-responders did not undergo breast surgery but received radiotherapy. Patients were divided into No surgery (n = 28), WLE (n = 44), Mastectomy (n = 49) groups.Comparisons of OS and DFS between groups showed statistically significant differences (p = 0.0003, p = 0.0007 respectively). The no surgery group showed low local recurrence (7.14%).

CONCLUSION

The observed slightly better long-term outcomes with low local recurrences in complete NAC-responders who did not undergo breast surgery but received radiotherapy could be linked to cautious response assessment and meticulous patient selection with early, biologically favourable breast cancer.Importance of PCR assessment cannot be underestimated if breast surgery were to be de-escalated or even omitted in complete NAC-responders.Considering the study limitations, avoiding surgery in all complete NAC-responders may still not be the preferred option. Future appropriate clinical trials with well-defined protocols may pave the way forward.

Breast cancer: comparison of quantitative dual-layer spectral CT and axillary ultrasonography for preoperative diagnosis of metastatic axillary lymph nodes

Background

Our aim was to compare the diagnostic performance of quantitative dual-layer spectral computed tomography (DLSCT) and axillary ultrasound (US) for diagnosing lymph node metastases in breast cancer patients.

Methods

DLSCT and axillary US were prospectively performed in 70 needle biopsy-verified breast cancer patients. Histopathology and imaging data were available for evaluation in 36 axillae from 34 patients. In each patient, ipsilateral, contralateral, and inguinal lymph nodes (LNs) were semiautomatically segmented, and iodine density, spectral slope, Z effective, virtual non-contrast (VNC), conventional CT HU values, and Δ contrast enhancement (ΔCE, conventional CT HU minus VNC) were measured. Using histopathology as reference, the diagnostic performance of DLSCT and axillary US was compared.

Results

Of 36 axillae, 23 had metastatic lymph nodes. Compared with non-metastatic LNs, metastatic LNs had significantly different iodine density (p = 0.021), spectral slope (p < 0.001), Z effective (p < 0.001), conventional CT HU values (p < 0.01), and ΔCE (p < 0.01). All DLSCT parameters were significantly different between arterial phase and portal-venous phase (p < 0.001) except for VNC (p = 0.092). ΔCE had the highest diagnostic performance (sensitivity 0.79, specificity 0.92, positive predictive value 0.95, negative predictive value 0.69) with a significantly increased sensitivity compared with conventional CT HU (p = 0.027). There were no significant differences between ΔCE and axillary US for sensitivity (p = 1.000) or specificity (p = 0.320).

Conclusions

DLSCT is a promising quantitative technique for evaluating LN metastases and could potentially reduce the need for sentinel LN biopsy.

The prognostic impact of mode of detection of axillary metastases for women with invasive breast cancer: A retrospective observational study

AIM

To identify the breast cancer specific survival (BCSS) associated with nodal metastasis identified by axillary core biopsy (ACB), and by sentinel node biopsy (SNB) compared with node negative patients. A further aim was to assess the prognostic effects of axillary ultrasound (US) features and amount of tumour in ACB specimens.

METHODS

Consecutive patients with cancer were identified from a database of US lesions undergoing breast biopsy. The three study groups were: a) those with metastasis identified by ACB, b) those undergoing immediate surgery with positive SNB and c) those undergoing immediate surgery with a negative SNB. US features and the amount of tumour in the ACB specimen were assessed by review of US images and pathological reports. BCSS was assessed using Kaplan Meier survival curves.

RESULTS

967 patients were included, with mean follow-up of 6.0 yrs. There were 90 breast cancer deaths: 26% of those with a positive ACB, 11% with a positive SNB and 4% of those with a negative SNB. BCSS was significantly different between the groups (p < 0.001) with hazard ratio, compared with the negative SNB group, of 7.8 (95% CI 4.4-13.7) for patients with positive ACB and 2.5 (95% CI 1.3-4.6) for positive SNB. Axillary US findings and assessment of the amount of tumour in the ACB did not influence survival.

CONCLUSION

This study suggests that women with a positive ACB have a worse BCSS compared to those with a positive SNB. This should be borne in mind when systemic therapy is being considered.

Neo-Adjuvant chemotherapy and its affects to the axilla-Can we safely downgrade axillary surgery to mirror the approach in the breast

The use of neo-adjuvant chemotherapy (NACT) to downgrade surgery in the breast from mastectomy to breast-conserving surgery is well-established. In certain patients, the use of adjuvant axillary radiotherapy can be safe and effective in place of axillary node clearance. What remains less clear are the alternative surgical options to the axilla following NACT. The aim of this study was to examine the effects of NACT in the axilla and whether downgrading axillary node clearance to axillary conserving surgery to mirror the approach in the breast may be a viable and safe practice. Patients undergoing neo-adjuvant chemotherapy were identified over a seven-year period between 2010 and 2017. Surgical plans were compared with pre- and post-chemotherapy. Histological information at the time of diagnosis was compared to surgical excision specimens. 349 patients were included for analysis, and 264 had axillary status documented at diagnosis. The average patient age was 51 years, and Grade 3, ER-positive, and Her2-negative cancers made the biggest histological subgroups. Complete pathological response (CPR) was seen in the breast in 27% of cases. 19% of patients requiring mastectomy had their surgery downgraded. Following NACT, axillary CPR was seen in 42% of patients and residual axillary nodal burden was limited to four nodes in 73% of patients. Axillary conserving surgery may be a safe alternative surgical approach in the downstaged axilla following neo-adjuvant chemotherapy. Advances in perioperative identification of suspicious nodes may be needed to facilitate progress.

Mode of presentation and skin thickening on ultrasound may predict nodal burden in breast cancer patients with a positive axillary core biopsy

OBJECTIVE

A number of pre-operative factors predicting nodal burden in females with breast cancer have recently been identified. The aim of this study is to assess if these factors independently influence nodal burden in females with a positive axillary core biopsy.

METHODS

All node positive patients detected on axillary core biopsy were identified in our cancer audit database. Mode of presentation, age, core tumour grade, core tumour type, ER and HER2 status were evaluated. Tumours were assessed for ultrasound size, distance of tumour-to-skin, presence of invasion of skin and diffuse skin thickening. Axillary lymph nodes were assessed for cortical thickness and presence of ultrasound replaced nodes. Statistical significance was ascertained using univariate logistic regression. A predictive model was produced following a multiple logistic regression model incorporating cross-validation and assessed using receiving operating characteristic curve.

RESULTS

115 patients' data were analysed. Patients referred because of symptoms (70% vs 38%, p = 0.005), and those with ultrasound skin thickening (87% vs 59%, p = 0.055) have higher nodal burden than those referred from screening or without skin thickening. These factors were significant after multivariate analysis. The final predictive model included mode of presentation, ultrasound tumour size, cortical thickness and presence of ultrasound skin thickening. The area under curve is 0.77.

CONCLUSION

We have shown that mode of presentation and ultrasound skin thickening are independent predictors of high nodal burden at surgery. A model has been developed to predict nodal burden pre-operatively, which may lead to avoidance of axillary node clearance in patients with lower nodal burden.

ADVANCES IN KNOWLEDGE

Method of presentation and skin involvement/proximity to skin by the primary tumour are known to influence outcome and nodal involvement respectively but have not been studied with regard to nodal burden. We have shown that mode of presentation and skin thickening at ultrasound are independent predictors of high nodal burden at surgery.

Shortcomings of ultrasound-guided fine needle aspiration in the axillary management of women with breast cancer

Background

Ultrasound, along with ultrasound-guided fine needle aspiration, is currently used for the axillary evaluation of breast cancer patients in order to identify candidates for axillary lymph node dissection. The aim of this study is to evaluate the accuracy of this tool in correctly identifying patients who may or may not benefit from axillary clearance in light of the ACOSOG Z0011 trial recommendations.

Methods

One hundred one patients (65 with positive US-FNA with corresponding axillary lymph node dissection (ALND), and 36 with negative US-FNA with corresponding ALND/sentinel lymph node biopsy) were studied for the number of involved axillary lymph nodes, tumor clinicopathologic features, and axillary radiologic findings.

Results

From the positive US-FNA group, 43% of patients had two or fewer positive lymph nodes upon ALND pathologic examination. In the US-FNA negative group, the negative predictive value for detecting axillary disease was 72.7%. With both groups combined, the sensitivity, specificity, PPV, and NPV of US-FNA for selecting patients based on axillary disease burden were 86%, 51.7%, 57%, and 83.3%, respectively.

Conclusion

Based on Z0011 guidelines, US-FNA is not a reliable tool in triaging patients in need for ALND and leads to overtreatment of 43% patients when positive, while depriving a small but significant percentage of patients from necessary therapy, when negative.

Surgical Oncology and Geriatric Patients

Geriatric medicine is a growing field filled with complicated patients who are susceptible to developing cancer. Surgical oncology is expanding while adapting to the increasing elderly population and creating novel treatment regimens for this group of patients. This article reviews surgical oncology in elderly patients and addresses surgical optimization, management of several cancer subtypes, surgical advances in minimally invasive surgery, and ethical considerations.

Meta-analysis of the diagnostic accuracy of ultrasound-guided fine-needle aspiration and core needle biopsy in diagnosing axillary lymph node metastasis

Background

Axillary lymph node status remains a significant prognostic indicator in breast cancer. Here, the diagnostic accuracy of ultrasound-guided fine-needle aspiration (US-FNA) and ultrasound-guided core needle biopsy (US-CNB) in axillary staging was compared.

Methods

A comprehensive search was undertaken of all published studies comparing the diagnostic accuracy of US-CNB and US-FNA of axillary lymph nodes in breast cancer. Studies were included if raw data were available on the diagnostic performance of both US-FNA and US-CNB, and compared with final histology results. Relevant data were extracted from each study for systematic review. Meta-analysis was performed using a random-effects model. The pooled sensitivity and specificity of US-FNA and US-CNB were obtained using a bivariable model. Summary receiver operating characteristic (ROC) graphs were created to confirm diagnostic accuracy.

Results

Data on a total of 1353 patients from six studies met the inclusion criteria and were included in the final analysis. US-CNB was superior to US-FNA in diagnosing axillary nodal metastases: sensitivity 88 (95 per cent c.i. 84 to 91) versus 74 (70 to 78) per cent respectively. Both US-CNB and US-FNA had a high specificity of 100 per cent. Reported complication rates were significantly higher for US-CNB compared with US-FNA (7·1 versus 1·3 per cent; P &lt; 0·001). Conversely, the requirement for repeat diagnostic procedures was significantly greater for US-FNA (4·0 versus 0·5 per cent; P &lt; 0·001).

Conclusion

US-CNB is a superior diagnostic technique to US-FNA for axillary staging in breast cancer.

Axillary Lymph Node Dissection in Patients with Breast Cancer and Sentinel Lymph Node Micrometastasis or Isolated Tumor Cells: Is it Necessary?

Aims and background

Sentinel lymph node biopsy is the standard method for axillary lymph node staging in patients with early stage breast cancer. The aim of the study was to evaluate the necessity of axillary lymph node dissection in patients with breast cancer and sentinel lymph node micrometastasis or isolated tumor cells.

Methods

Sentinel lymph node biopsy was performed in 136 patients for breast cancer staging: 16 of them (11.7%) were found to have micrometastasis or isolated tumor cells and underwent axillary lymph node dissection. Micrometastases were considered when tumor invasion was <2 mm and >0.2 mm in diameter and isolated tumor cells when detected alone or in clusters of <0.2 mm in diameter. The dissection of the three axillary lymph node levels of Berg was performed in all cases.

Results

Two patients (12.5%) presented isolated tumor cells and 14 (87.5%) micrometastasis in the sentinel lymph node. Among them, 25% presented nonsentinel axillary lymph node tumor invasion, whereas 75% had no further nodal involvement.

Conclusions

Results suggest that micrometastasis or isolated tumor cells of the sentinel lymph node represent the only site of cancer involvement of the axilla, especially in patients with early breast tumors, and that axillary lymph node dissection may be unnecessary in these cases and represent an overtreatment.

Tubular Carcinoma of the Breast: A Single Institution's Experience of a Favorable Prognosis

Tubular carcinoma is a subtype of invasive breast cancer that comprises 1 to 4 per cent of invasive breast cancers. Prior studies show nearly 100 per cent 15 year survival rate for tubular carcinoma compared to the 89.2 per cent five year survival of all breast cancers. These encouraging statistics beg the question should tubular cancers be treated as other invasive cancers, or can some patients be spared an invasive procedure or the side effects of adjuvant therapy? Fifty-seven cases of tubular carcinoma over 16 years were analyzed. All relevant aspects of the patient's history, treatment, and outcomes were documented. The aim was compare treatment outcomes of tubular breast cancer outcomes to that of all invasive breast cancers. Of the 57 patients, local recurrence was seen in two patients (3.5%) only one of which recurred as a tubular carcinoma (1.75%). There were no cancer-related mortalities. A look into our institution's data supported the notion that tubular carcinoma of the breast is a less aggressive histological type. Of our 57 cases, only two recurrences (3.5%) were noted and there were no cancer-related mortalities. Interestingly only one patient (1.75%) recurred as tubular carcinoma. Without controlling for adjuvant therapy, recommendations cannot be made for a less aggressive treatment plan at this point. Future randomized controlled trials may lead to a less aggressive treatment plan for this favorable subtype. On the basis of this study and others like it, physicians can give evidenced-based favorable prognosis with a diagnosis of tubular carcinoma of the breast.

Pooled long-term outcomes from two randomized trials of axillary node sampling with axillary radiotherapy versus axillary node clearance in patients with operable node-positive breast cancer

BACKGROUND

The aim was to determine long-term overall, breast cancer-specific and metastasis-free survival as well as axillary relapse rate from a pooled analysis of two randomized trials in women with operable breast cancer. These trials compared axillary node sampling (ANS), combined with axillary radiotherapy (AXRT) if the sampled nodes were involved, with axillary node clearance (ANC).

METHODS

Data from two clinical trials at the Edinburgh Breast Unit that randomized patients between 1980 and 1995 were pooled. Long-term survival was analysed using Kaplan-Meier curves and Cox regression, with separate analyses for patients with node-positive (ANS + AXRT versus ANC) and node-negative (ANS versus ANC) disease.

RESULTS

Of 855 women randomized, 799 were included in the present analysis after a median follow-up of 19·4 years. Some 301 patients (37·7 per cent) had node-positive disease. There was no evidence of a breast cancer survival advantage for ANS versus ANC in patients with node-negative disease (hazard ratio (HR) 0·88, 95 per cent c.i. 0·58 to 1·34; P = 0·557), or for ANS + AXRT versus ANC in those with node-positive breast cancer (HR 1·07, 0·77 to 1·50; P = 0·688). There was no metastasis-free survival advantage for ANS versus ANC in patients with node-negative tumours (HR 1·03, 0·70 to 1·51; P = 0·877), or ANS + AXRT versus ANC in those with node-positive disease (HR 1·03, 0·75 to 1·43; P = 0·847). Node-negative patients who underwent ANS had a higher risk of axillary recurrence than those who had ANC (HR 3·53, 1·29 to 9·63; P = 0·014). Similarly, among women with node-positive tumours, the risk of axillary recurrence was greater after ANS + AXRT than ANC (HR 2·64, 1·00 to 6·95; P = 0·049).

CONCLUSION

Despite a higher rate of axillary recurrence with ANS combined with radiotherapy to the axilla, ANC did not improve overall, breast cancer-specific or metastasis-free survival. Axillary recurrence is thus not a satisfactory endpoint when comparing axillary treatments.

Phase III randomized equivalence trial of early breast cancer treatments with or without axillary clearance in post-menopausal patients results after 5 years of follow-up

BACKGROUND

Axillary lymph node clearance (ALNC) improves locoregional control and provides prognostic information for early breast cancer treatment, but effects on survival are controversial. This multicentre, randomized pragmatic equivalence trial compares outcomes for post-menopausal early invasive breast cancer patients after locoregional treatment with ALNC and adjuvant therapies to outcomes after locoregional treatment without ALNC and adjuvant therapies.

METHODS

From 1995-2005, women aged ≥ 50 years with early breast cancer (tumor ≤ 10 mm) and clinically-negative axillary nodes were randomized to receive treatment with ALNC (Ax) or without (no-Ax). Adjuvant therapies were prescribed according to hormonal receptor status and individual histological results. The primary endpoint was overall survival (OS); secondary endpoints were event-free survival (EFS) and functional outcomes. The trial was terminated due to lack of equivalence and low accrual after first interim analyses.

TRIAL REGISTRATION

NCT00210236.

RESULTS

Of 625 patients, 297 no-Ax and 310 Ax patients were maintained for final per-protocol analyses. OS and EFS at five years were not equivalent (Ax vs. no-Ax: 98% vs. 94% and 96% vs. 90% respectively). Recurrence was higher for no-Ax, particularly in the first five years after surgery. Axillary nodes were positive for 14% Ax patients but only 2% no-Ax patients experienced axillary node recurrence. Functional impairments were greater after ALNC.

CONCLUSION

Our results fail to demonstrate equivalence of outcomes when ALNC is omitted from post-menopausal early breast cancer patient treatment. However the low locoregional recurrence rates warrant further examination over a longer duration, in particular to consider whether these would impact on survival.

Clinical cancer advances 2010: annual report on progress against cancer from the American Society of Clinical Oncology

A MESSAGE FROM ASCO'S PRESIDENT

Like many health professionals who care for people with cancer, I entered the field because of specific patients who touched my heart. They still do. In an effort to weave together my personal view of what the American Society of Clinical Oncology (ASCO) stands for and the purpose the organization serves, my presidential theme this year is “Patients. Pathways. Progress.” Patients come first. Caring for patients is the most important, rewarding aspect of being an oncology professional. At its best, the relationship between doctor and patient is compassionate and honest—and a relationship of mutual respect. Many professional organizations have an interest in cancer, but no other society is so focused on the entire spectrum of cancer care, education, and research. Nor is any other society as particularly interested in bringing new treatments to our patients through clinical trials as ASCO is. Clinical trials are the crux for improving treatments for people with cancer and are critical for continued progress against the disease. “Pathways” has several meanings. Some pathways are molecular—like the cancer cell's machinery of destruction, which we have only begun to understand in recent years. But there are other equally important pathways, including the pathways new therapies follow as they move from bench to bedside and the pathways patients follow during the course of their diseases. Improved understanding of these pathways will lead to new approaches in cancer care, allowing doctors to provide targeted therapies that deliver improved, personalized treatment. The best pathway for patients to gain access to new therapies is through clinical trials. Trials conducted by the National Cancer Institute's Cooperative Group Program, a nationwide network of cancer centers and physicians, represent the United States' most important pathway for accelerating progress against cancer. This year, the Institute of Medicine released a report on major challenges facing the Cooperative Group Program. Chief among them is the fact that funding for the program has been nearly flat since 2002. ASCO has called for a doubling of funding for cooperative group research within five years and supports the full implementation of the Institute of Medicine recommendations to revitalize the program. ASCO harnesses the expertise and resources of its 28,000 members to bring all of these pathways together for the greater good of patients. Progress against cancer is being made every day—measurable both in our improved understanding of the disease and in our ability to treat it. A report issued in December 2009 by the National Cancer Institute, the Centers for Disease Control and Prevention, the American Cancer Society, and the North American Association of Central Cancer Registries found that rates of new diagnoses and rates of death resulting from all cancers combined have declined significantly in recent years for men and women overall and for most racial and ethnic populations in the United States. The pace of progress can be and needs to be hastened. Much remains to be done. Sustained national investment in cancer research is needed to bring better, more effective, less toxic treatments to people living with cancer. Pathways to progress continue in the clinic as doctors strive to find the right treatments for the right patients, to understand what represents the right treatments, and to partner with patients and caregivers for access to those treatments. This report demonstrates that significant progress is being made on the front lines of clinical cancer research. But although our nation's investment in this research is paying off, we must never forget the magnitude of what lies ahead. Cancer remains the number two killer of Americans. Future progress depends on continued commitment, from both ASCO and the larger medical community. George W. Sledge Jr, MD President American Society of Clinical Oncology

Risk factors for lymphedema after breast cancer treatment

BACKGROUND

As cancer treatments evolve, it is important to reevaluate their effect on lymphedema risk in breast cancer survivors.

METHODS

A population-based random sample of 631 women from metropolitan Philadelphia, Pennsylvania, diagnosed with incident breast cancer in 1999 to 2001, was followed for 5 years. Risk factor information was obtained by questionnaire and medical record review. Lymphedema was assessed with a validated questionnaire. Using Cox proportional hazards models, we estimated the relative incidence rates [hazard ratios (HR)] of lymphedema with standard adjusted multivariable analyses ignoring interactions, followed by models including clinically plausible treatment interactions.

RESULTS

Compared with no lymph node surgery, adjusted HRs for lymphedema were increased following axillary lymph node dissection [ALND; HR, 2.61; 95% confidence interval (95% CI), 1.77-3.84] but not sentinel lymph node biopsy (SLNB; HR, 1.04; 95% CI, 0.58-1.88). Risk was not increased following irradiation [breast/chest wall only: HR, 1.18 (95% CI, 0.80-1.73); breast/chest wall plus supraclavicular field (+/- full axilla): HR, 0.86 (95% CI, 0.48-1.54)]. Eighty-one percent of chemotherapy was anthracycline based. The HR for anthracycline chemotherapy versus no chemotherapy was 1.46 (95% CI, 1.04-2.04), persisting after stratifying on stage at diagnosis or number of positive nodes. Treatment combinations involving ALND or chemotherapy resulted in approximately 4- to 5-fold increases in HRs for lymphedema [e.g., HR of 4.16 (95% CI, 1.32-12.45) for SLNB/chemotherapy/no radiation] compared with no treatment.

CONCLUSION

With standard multivariable analyses, ALND and chemotherapy increased lymphedema risk whereas radiation therapy and SLNB did not. However, risk varied by combinations of exposures.

IMPACT

Treatment patterns should be considered when counseling and monitoring patients for lymphedema.