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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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2
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Kim BK, Woo J, Lee J, Kang E, Baek SY, Lee S, Lee HJ, Lee J, Sun WY. Survival Outcomes Based on Axillary Surgery in Ductal Carcinoma In Situ: A Nationwide Study From the Korean Breast Cancer Society. J Breast Cancer 2024; 27:1-13. [PMID: 38433090 PMCID: PMC10912575 DOI: 10.4048/jbc.2023.0221] [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: 09/29/2023] [Revised: 11/20/2023] [Accepted: 01/27/2024] [Indexed: 03/05/2024] Open
Abstract
PURPOSE In total mastectomy (TM), sentinel lymph node biopsy (SLNB) is recommended but can be omitted for breast-conserving surgery (BCS) in patients with ductal carcinoma in situ (DCIS). However, concerns regarding SLNB-related complications and their impact on quality of life exist. Consequently, further research is required to evaluate the role of axillary surgeries, including SLNB, in the treatment of TM. We aimed to explore the clinicopathological factors and outcomes associated with axillary surgery in patients with a final diagnosis of pure DCIS who underwent BCS or TM. METHODS We retrospectively analyzed large-scale data from the Korean Breast Cancer Society registration database, highlighting on patients diagnosed with pure DCIS who underwent surgery and were categorized into two groups: BCS and TM. Patients were further categorized into surgery and non-surgery groups according to their axillary surgery status. The analysis compared clinicopathological factors and outcomes according to axillary surgery status between the BCS and TM groups. RESULTS Among 18,196 patients who underwent surgery for DCIS between 1981 and 2022, 11,872 underwent BCS and 6,324 underwent TM. Both groups leaned towards axillary surgery more frequently for large tumors. In the BCS group, clinical lymph node status was associated with axillary surgery (odds ratio, 11.101; p = 0.003). However, in the TM group, no significant differences in these factors were observed. Survival rates did not vary between groups according to axillary surgery performance. CONCLUSION The decision to perform axillary surgery in patients with a final diagnosis of pure DCIS does not affect the prognosis, regardless of the breast surgical method. Furthermore, regardless of the breast surgical method, axillary surgery, including SLNB, should be considered for high-risk patients, such as those with large tumors. This may reduce unnecessary axillary surgery and enhance the patients' quality of life.
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Affiliation(s)
- Bong Kyun Kim
- Department of Surgery, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Joohyun Woo
- Department of Surgery, Ewha Womans University Mokdong Hospital, Ewha Womans University College of Medicine, Seoul, Korea
| | - Jeeyeon Lee
- Department of Surgery, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Eunhye Kang
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Soo Yeon Baek
- Department of Surgery, Ajou University Medical Center, Ajou University School of Medicine, Suwon, Korea
| | - Seokwon Lee
- Department of Surgery, Biomedical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Hyouk Jin Lee
- Breast-Thyroid Center, Saegyaero Hospital, Busan, Korea
| | - Jina Lee
- Department of Surgery, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Woo Young Sun
- Department of Surgery, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
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van Hemert AKE, van Duijnhoven FH, Vrancken Peeters MJTFD. This house believes that: MARI/TAD is better than sentinel node biopsy after PST for cN+ patients. Breast 2023; 71:89-95. [PMID: 37562108 PMCID: PMC10432821 DOI: 10.1016/j.breast.2023.06.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 06/03/2023] [Accepted: 06/28/2023] [Indexed: 08/12/2023] Open
Abstract
The increasing use and effectiveness of primary systemic treatment (PST) enables tailored locoregional treatment. About one third of clinically node positive (cN+) breast cancer patients achieve pathologic complete response (pCR) of the axilla, with higher rates observed in Human Epidermal growth factor Receptor (HER)2-positive or triple negative (TN) breast cancer subtypes. Tailoring axillary treatment for patients with axillary pCR is necessary, as they are unlikely to benefit from axillary lymph node dissection (ALND), but may suffer complications and long-term morbidity such as lymphedema and impaired shoulder motion. By combining pre-PST and post-PST axillary staging techniques, ALND can be omitted in most cN + patients with pCR. Different post-PST staging techniques (MARI/TAD/SN) show low or ultra-low false negative rates for detection of residual disease. More importantly, trials using the MARI (Marking Axillary lymph nodes with Radioactive Iodine seeds) procedure or sentinel lymph node biopsy (SLNB) as axillary staging technique post-PST have already shown the safety of tailoring axillary treatment in patients with an excellent response. Tailored axillary treatment using the MARI procedure in stage I-III breast cancer resulted in 80% reduction of ALND and excellent five-year axillary recurrence free interval (aRFI) of 97%. Similar oncologic outcomes were seen for post-SLNB in stage I-II patients. The MARI technique requires only one invasive procedure pre-NST and a median of one node is removed post-PST, whereas for the SLNB and TAD techniques two to four nodes are removed. A disadvantage of the MARI technique is its use of radioactive iodine, which is subject to extensive regulations.
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Affiliation(s)
- Annemiek K E van Hemert
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066, CX, Amsterdam, the Netherlands
| | - Frederieke H van Duijnhoven
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066, CX, Amsterdam, the Netherlands
| | - Marie-Jeanne T F D Vrancken Peeters
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066, CX, Amsterdam, the Netherlands; Department of Surgery, Amsterdam University Medical Center, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands.
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Montagna G, Barrio AV. Managing the Morbidity: Individualizing Risk Assessment, Diagnosis, and Treatment Options for Upper Extremity Lymphedema. Surg Oncol Clin N Am 2023; 32:705-724. [PMID: 37714638 DOI: 10.1016/j.soc.2023.05.004] [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] [Indexed: 09/17/2023]
Abstract
In the setting where breast cancer-related lymphedema (BCRL) remains a feared and common complication of breast cancer, here we review important factors for the development, diagnosis, prevention, and treatment of BCRL. We find that race/ethnicity affect BCRL development risk, that future studies should focus on understanding the biological reasons behind the increased susceptibility of certain racial minorities to BCRL, that surveillance, early detection, exercise programs, and arm compression can reduce the risk of BCRL, and that surgical techniques to preserve and restore lymphatic drainage being evaluated in randomized trials may become transformative in reducing BCRL risk for high-risk patients.
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Affiliation(s)
- Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY 10065, USA
| | - Andrea V Barrio
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY 10065, USA.
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Cobb A, DeSnyder SM. Risk Factors for Breast Cancer-Related Lymphedema, Risk Reduction, and Myths about Precautionary Behaviors. CURRENT BREAST CANCER REPORTS 2023. [DOI: 10.1007/s12609-023-00474-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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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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Yang J, He T, Wu Y, Fu Z, Lv Q, Lu S, Wang X, Li H, Wang J, Chen J. Nanoparticle-assisted axillary staging: an alternative approach after neoadjuvant chemotherapy in patients with pretreatment node-positive breast cancers. Breast Cancer Res Treat 2022; 192:573-582. [PMID: 35129717 DOI: 10.1007/s10549-022-06539-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 01/29/2022] [Indexed: 02/08/2023]
Abstract
PURPOSE In order to achieve an optimized method of axillary staging after neoadjuvant chemotherapy (NAC) in breast cancer patients with pretreatment positive axillary lymph nodes, we evaluated the feasibility and accuracy of nanoparticle-assisted axillary staging (NAAS) which combines carbon nanoparticles with standard sentinel lymph node biopsy (SLNB) with radioisotope and blue dye. METHODS Invasive breast cancer patients with pre-NAC positive axillary lymph nodes who converted to ycN0 and received surgeries from November 2020 to March 2021 were included. All patients underwent ipsilateral NAAS followed by axillary lymph node dissection. Detection rate (DR), false-negative rate (FNR), negative predictive value (NPV) and accuracy of axillary staging were calculated. RESULTS Eighty of 136 (58.8%) breast cancer patients converted to ycN0 after NAC and received NAAS. The DR, NPV and accuracy was 95.0%, 93.3% and 97.4% for NAAS, respectively. And the FNR was 4.2% (2/48) for NAAS, which was lower than that of standard dual-tracer SLNB (SD-SLNB) (9.5%, 4/42). Pretreatment clinical T4 classification was a risk factor for detection failure in NAAS (p = 0.016). When patients with pretreatment inflammatory breast cancers were excluded from analysis, FNR dropped to 2.2% (1/45) for NAAS. CONCLUSION NAAS revealed great performance in invasive breast cancer patients with pre-NAC positive axillary lymph nodes who converted to ycN0. The application of NAAS reached a better balance between more accurate axillary evaluation and less intervention. Trial registration Chictr.org.cn (ChiCTR2000039814). Registered Nov 11, 2020.
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Affiliation(s)
- Jiqiao Yang
- Department of Breast Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, China.,Clinical Research Center for Breast Disease, West China Hospital, Sichuan University, Chengdu, China
| | - Tao He
- Department of Breast Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, China
| | - Yunhao Wu
- Department of Breast Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, China
| | - Zhoukai Fu
- Department of Breast Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, China
| | - Qing Lv
- Department of Breast Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, China
| | - Shan Lu
- Department of Breast Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, China
| | - Xiaodong Wang
- Department of Breast Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, China
| | - Hongjiang Li
- Department of Breast Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, China
| | - Jing Wang
- Department of Breast Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, China
| | - Jie Chen
- Department of Breast Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, China.
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Underestimation of invasive breast carcinoma in patients with initial diagnosis of ductal carcinoma in situ: Size matters. Cir Esp 2021; 99:655-659. [PMID: 34749924 DOI: 10.1016/j.cireng.2021.02.006] [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: 09/11/2020] [Accepted: 10/26/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND The aim of our study was to identify those patients with preoperative diagnosis of ductal carcinoma in situ (DCIS) and high risk of upstaging to invasive breast carcinoma (IBC), in whom sentinel lymph node biopsy (SLNB) should be considered. MATERIALS AND METHODS One-hundred and five DCIS patients treated with breast-conserving surgery (BCS) or mastectomy were studied. Preoperative features of the tumours were analyzed to investigate its association with underestimation of IBC on final pathology. RESULTS Overall, the underestimation rate of IBC was 16.2%. The underestimation rate was highest in lesions with initial size >2 cm compared with those with size ≤2 cm (26.8% vs. 4.1%, respectively; p < 0.003). Eighty-eight patients (83.8%) underwent concurrent SLNB and only one case had lymph node involvement (1.1%). CONCLUSIONS SLNB should be considered in DCIS patients receiving BCS with lesions greater than 2 cm since approximately one in four will harbour an IBC.
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Roberts SA, Gillespie TC, Shui AM, Brunelle CL, Daniell KM, Locascio JJ, Naoum GE, Taghian AG. Weight loss does not decrease risk of breast cancer-related arm lymphedema. Cancer 2021; 127:3939-3945. [PMID: 34314022 PMCID: PMC8516692 DOI: 10.1002/cncr.33819] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 06/06/2021] [Accepted: 06/28/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND The goal of this study was to determine the relationship between postoperative weight change and breast cancer-related lymphedema (BCRL). METHODS In this cohort study, 1161 women underwent unilateral breast surgery for breast cancer from 2005 to 2020 and were prospectively screened for BCRL. Arm volume measurements were obtained via an optoelectronic perometer preoperatively, postoperatively, and in the follow-up setting every 6 to 12 months. Mean follow-up from preoperative baseline was 49.1 months. The main outcome was BCRL, defined as a relative volume change of the ipsilateral arm of ≥10% at least 3 months after surgery. RESULTS A total of 92 patients (7.9%) developed BCRL. Net weight loss versus net weight gain from baseline to last follow-up was not protective against developing BCRL (hazard ratio, 1.38; 95% confidence interval, 0.89-2.13; P = .152). CONCLUSIONS Although weight loss may be recommended as part of an individualized lifestyle management program for overall health, weight loss alone may not decrease the risk of developing BCRL.
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Affiliation(s)
- Sacha A. Roberts
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston MA, 02114
| | - Tessa C. Gillespie
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston MA, 02114
| | - Amy M. Shui
- Biostatistics Center, Massachusetts General Hospital, Harvard Medical School, Boston MA, 02114
| | - Cheryl L. Brunelle
- Department of Physical and Occupational Therapy, Massachusetts General Hospital, Boston MA, 02114
| | - Kayla M. Daniell
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston MA, 02114
| | - Joseph J. Locascio
- Biostatistics Center, Massachusetts General Hospital, Harvard Medical School, Boston MA, 02114
| | - George E. Naoum
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston MA, 02114
| | - Alphonse G. Taghian
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston MA, 02114
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Lin Y, Xu Y, Wang C, Song Y, Huang X, Zhang X, Cao X, Sun Q. Loco-regional therapy and the risk of breast cancer-related lymphedema: a systematic review and meta-analysis. Breast Cancer 2021; 28:1261-1272. [PMID: 34106427 DOI: 10.1007/s12282-021-01263-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 05/20/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND This meta-analysis was designed to assess the association between two loco-regional therapies, regional nodal irradiation (RNI) and axillary lymph node dissection (ALND), and breast cancer-related lymphoedema (BCRL). METHODS We searched PubMed, Science Direct, Embase, and BMJ databases for clinical studies published between January 1, 2010 and January 1, 2020, which assessed risk factors and incidence/prevalence of BCRL. Two investigators independently selected articles to extract relative data and calculate corresponding exact binomial 95% confidence intervals (CIs). In total, 93 articles were reviewed, from which 19 studies were selected. The extracted data were pooled using a random-effects mixed model. RESULTS The incidence of lymphedema in the selected studies ranged from 3% to 36.7%, with a pooled incidence of 14.29% (95% CI 13.79-14.79). The summary odds ratio/risk ratio (OR/RR) of ALND vs. no-ALND was 3.67 (95% CI 2.25-5.98) with a heterogeneity (I2) of 81% (P < 0.00001). After excluding the studies with an abnormally high risk of lymphedema from self-reporting, the summary hazard ratio (HR) was 2.99 (95% CI 2.44-3.66) with no heterogeneity (I2 = 0%, P = 0.83). The summary OR/RR of patients with vs. without radiotherapy (RT) was 1.82 (95% CI 0.92-3.59), but the RR of RT to breast/chest vs. both axillary and supraclavicular areas was 2.66 (95% CI 0.73-9.70). CONCLUSION Regional nodal irradiation has a significantly higher risk for developing lymphedema than irradiation of the breast/chest wall. Axillary dissection and axillary RT have a similar risk for early-onset of breast cancer-related lymphoedema, although the risk trends higher for axillary dissection.
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Affiliation(s)
- Yan Lin
- Department of Breast Disease, Peking Union Medical College Hospital, Peking Union Medical College, 1 Shuaifuyuan, Wangfujing, Beijing, 100730, China
| | - Ying Xu
- Department of Breast Disease, Peking Union Medical College Hospital, Peking Union Medical College, 1 Shuaifuyuan, Wangfujing, Beijing, 100730, China
| | - Changjun Wang
- Department of Breast Disease, Peking Union Medical College Hospital, Peking Union Medical College, 1 Shuaifuyuan, Wangfujing, Beijing, 100730, China
| | - Yu Song
- Department of Breast Disease, Peking Union Medical College Hospital, Peking Union Medical College, 1 Shuaifuyuan, Wangfujing, Beijing, 100730, China
| | - Xin Huang
- Department of Breast Disease, Peking Union Medical College Hospital, Peking Union Medical College, 1 Shuaifuyuan, Wangfujing, Beijing, 100730, China
| | - Xiaohui Zhang
- Department of Breast Disease, Peking Union Medical College Hospital, Peking Union Medical College, 1 Shuaifuyuan, Wangfujing, Beijing, 100730, China
| | - Xi Cao
- Department of Breast Disease, Peking Union Medical College Hospital, Peking Union Medical College, 1 Shuaifuyuan, Wangfujing, Beijing, 100730, China
| | - Qiang Sun
- Department of Breast Disease, Peking Union Medical College Hospital, Peking Union Medical College, 1 Shuaifuyuan, Wangfujing, Beijing, 100730, China.
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11
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Lymphatic dysfunction on indocyanine green lymphography in breast cancer patients undergoing sentinel lymph node biopsy. J Plast Reconstr Aesthet Surg 2021; 74:1931-1971. [PMID: 34148833 DOI: 10.1016/j.bjps.2021.05.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 03/30/2021] [Accepted: 05/27/2021] [Indexed: 11/20/2022]
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12
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Bouzón Alejandro A, Iglesias López Á, Acea Nebril B, García Jiménez ML, Díaz Carballada CC, Varela Romero JR. Underestimation of invasive breast carcinoma in patients with initial diagnosis of ductal carcinoma in situ: Size matters. Cir Esp 2021; 99:S0009-739X(20)30350-X. [PMID: 33541705 DOI: 10.1016/j.ciresp.2020.10.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 10/23/2020] [Accepted: 10/26/2020] [Indexed: 11/20/2022]
Abstract
INTRODUCTION The aim of our study was to identify those patients with preoperative diagnosis of ductal carcinoma in situ (DCIS) and high risk of upstaging to invasive breast carcinoma (IBC), in whom sentinel lymph node biopsy (SLNB) should be considered. METHODS One-hundred and five DCIS patients treated with breast-conserving surgery (BCS) or mastectomy were studied. Preoperative features of the tumors were analyzed to investigate its association with underestimation of IBC on final pathology. RESULTS Overall, the underestimation rate of IBC was 16.2%. The underestimation rate was highest in lesions with initial size >2 cm compared with those with size ≤2 cm (26.8% vs. 4.1%, respectively; p < 0.003). Eighty-eight patients (83.8%) underwent concurrent SLNB and only one case had lymph node involvement (1.1%). CONCLUSIONS SLNB should be considered in DCIS patients receiving BCS with lesions greater than 2 cm since approximately one in four will harbor an IBC.
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Affiliation(s)
- Alberto Bouzón Alejandro
- Unidad de Mama, Servicio de Cirugía General, Complejo Hospitalario Universitario A Coruña, España.
| | - Ángela Iglesias López
- Unidad de Mama, Servicio de Radiología, Complejo Hospitalario Universitario A Coruña, España
| | - Benigno Acea Nebril
- Unidad de Mama, Servicio de Cirugía General, Complejo Hospitalario Universitario A Coruña, España
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13
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Kim HK, Ju YW, Lee JW, Kim KE, Jung J, Kim Y, Lee HB, Moon HG, Noh DY, Seo KS, Han W. Association between Number of Retrieved Sentinel Lymph Nodes and Breast Cancer-related Lymphedema. J Breast Cancer 2021; 24:63-74. [PMID: 33634621 PMCID: PMC7920859 DOI: 10.4048/jbc.2021.24.e9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 01/17/2021] [Accepted: 01/17/2021] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Sentinel lymph node biopsy (SLNB) has become a standard axillary staging surgery for early breast cancer, and the proportion of patients requiring axillary lymph node dissection (ALND) is decreasing. We aimed to evaluate the association between the number of sentinel lymph nodes (SLNs) retrieved and the risk of lymphedema of the ipsilateral arm. METHODS Prospectively collected medical records of 910 patients were reviewed. Lymphedema was defined as a difference in circumference > 2 cm compared to the contralateral arm and/or having clinical records of lymphedema treatment in the rehabilitation clinic. RESULTS Together with an objective and subjective assessment of lymphedema, 36 patients (6.1%) had lymphedema in the SLNB group and 85 patients (27.0%) had lymphedema in the ALND group (p < 0.001). In a multivariate analysis of the whole cohort, risk factors significantly associated risk with the development of lymphedema were body mass index, mastectomy (vs. breast-conserving surgery), ALND, and radiation therapy. In logistic regression models in the SLNB group only, there was no correlation between the number of retrieved SLNs and the incidence of lymphedema. In addition, in the Pearson correlation analysis, no correlation was observed between the number of retrieved SLNs and the difference in circumference between the ipsilateral and contralateral upper extremities (correlation coefficients = 0.067, p =0.111). CONCLUSION The risk of lymphedema in breast cancer surgery and adjuvant treatments is multifactorial. The number of retrieved lymph nodes during sentinel biopsy was not associated with the incidence of lymphedema.
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Affiliation(s)
- Hong Kyu Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.,Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Young Wook Ju
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jun Woo Lee
- Department of Surgery, Ewha Womans University Medical Center, Seoul, Korea
| | - Kyoung Eun Kim
- Pusan National University Hospital, Busan Cancer Center, Busan, Korea
| | - Jigwang Jung
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Yumi Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Han Byoel Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hyeong Gon Moon
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.,Cancer Research Institute, Seoul National University, Seoul, Korea
| | - Dong Young Noh
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.,Cancer Research Institute, Seoul National University, Seoul, Korea
| | - Kwan Sik Seo
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Wonshik Han
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.,Cancer Research Institute, Seoul National University, Seoul, Korea.
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14
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Xu L, Yang J, Du Z, Liang F, Xie Y, Long Q, Chen J, Zeng H, Lv Q. Redefining Criteria to Ensure Adequate Sentinel Lymph Node Biopsy With Dual Tracer for Breast Cancer. Front Oncol 2020; 10:588067. [PMID: 33344240 PMCID: PMC7744718 DOI: 10.3389/fonc.2020.588067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 11/06/2020] [Indexed: 02/05/2023] Open
Abstract
Background For sentinel lymph node biopsy (SLNB) in patients with breast cancer, the dual tracer of blue dye and radioisotope with the 10% rule that all nodes with radioactive count of 10% or more of the hottest node ex vivo should be removed is widely accepted. However, the cut-off point of radioactivity is being questioned for possibly excessive removal of negative nodes. Methods To compare different percentile rules and optimize the criteria for identifying SLNs, we established a database which prospectively collected the radioactivity, status of blue dye and the pathological results of each SLN in breast cancer patients who successfully underwent SLNB with a combination of methylene blue and radioisotope. Results A total of 2,529 SLNs from 1,039 patients were identified from August 2010 to August 2019. 16.4% (414/2,529) positive nodes were removed at a cost of 83.6% (2115/2,529) negative nodes removed excessively. Up to 17.9% (375/2,115) negative nodes were removed as radioactively hot nodes without blue staining. By gradually increasing the threshold by each 10%, the number of negative nodes identified reduced by 18.2% (385/2,115) with only three node-positive patients (1.0%) missed to be identified using the “40% + blue” rule. In patients with ≥ 2 SLNs removed, 12.3% (238/1,942) negative nodes avoided unnecessary removal with only 0.8% (2/239) positive patients missed with the “hottest two + blue” rule. Conclusions Our data indicated that the “40% + blue” rule or the “hottest two + blue” rule for SLNB with the dual tracer of blue dye and radioisotope may be considered as a potential alternative rule to minimize extra nodes resected. Nonetheless, it should be validated by prospective trials with long-term follow-up.
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Affiliation(s)
- Li Xu
- Department of Breast Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jiqiao Yang
- Department of Breast Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Zhenggui Du
- Department of Breast Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Faqing Liang
- Department of Breast Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yanyan Xie
- Department of Breast Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Quanyi Long
- Department of Breast Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jie Chen
- Department of Breast Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Helin Zeng
- Department of Breast Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Qing Lv
- Department of Breast Surgery, West China Hospital, Sichuan University, Chengdu, China
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15
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McEvoy AM, Poplack S, Nickel K, Olsen MA, Ademuyiwa F, Zoberi I, Odom E, Yu J, Chang SH, Gillanders WE. Cost-effectiveness analyses demonstrate that observation is superior to sentinel lymph node biopsy for postmenopausal women with HR + breast cancer and negative axillary ultrasound. Breast Cancer Res Treat 2020; 183:251-262. [PMID: 32651755 DOI: 10.1007/s10549-020-05768-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 06/22/2020] [Indexed: 01/20/2023]
Abstract
PURPOSE To evaluate the cost-effectiveness of axillary observation versus sentinel lymph node biopsy (SLNB) after negative axillary ultrasound (AUS). In patients with clinical T1-T2 N0 breast cancer and negative AUS, SLNB is the current standard of care for axillary staging. However, SLNB is costly, invasive, decreasing in importance for medical decision-making, and is not considered therapeutic. Observation alone is currently being evaluated in randomized clinical trials, and is thought to be non-inferior to SLNB for patients with negative AUS. METHODS We performed cost-effectiveness analyses of observation versus SLNB after negative AUS in postmenopausal women with clinical T1-T2 N0, HR+/HER2- breast cancer. Costs at the 2016 price level were evaluated from a third-party commercial payer perspective using the MarketScan® Database. We compared cost, quality-adjusted life years (QALYs), and net monetary benefit (NMB). Multiple sensitivity analyses varying baseline probabilities, costs, utilities, and willingness-to-pay thresholds were performed. RESULTS Observation was superior to SLNB for patients with N0 and N1 disease, and for the entire patient population (NMB in US$: $655,659 for observation versus $641,778 for SLNB for the entire patient population). In the N0 and N1 groups, observation incurred lower cost and was associated with greater QALYs. SLNB was superior for patients with > 3 positive lymph nodes, representing approximately 5% of the population. Sensitivity analyses consistently demonstrated that observation is the optimal strategy for AUS-negative patients. CONCLUSION Considering both cost and effectiveness, observation is superior to SLNB in postmenopausal women with cT1-T2 N0, HR+/HER2- breast cancer and negative AUS.
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Affiliation(s)
- Aubriana M McEvoy
- Department of Surgery, Section of Endocrine and Oncologic Surgery, Washington University St. Louis, St. Louis, MO, USA
- School of Medicine, University of Washington, Seattle, WA, USA
| | - Steven Poplack
- Department of Diagnostic Radiology, Section of Breast Imaging, Washington, University St. Louis, St. Louis, MO, USA
- Siteman Cancer Center, St. Louis, MO, USA
| | - Katelin Nickel
- Division of Infectious Diseases, Center for Administrative Data Research, Washington University St. Louis, St. Louis, MO, USA
| | - Margaret A Olsen
- Siteman Cancer Center, St. Louis, MO, USA
- Division of Infectious Diseases, Center for Administrative Data Research, Washington University St. Louis, St. Louis, MO, USA
- Department of Surgery, Division of Public Health Science, Washington University St. Louis, St. Louis, MO, USA
| | - Foluso Ademuyiwa
- Siteman Cancer Center, St. Louis, MO, USA
- Department of Medical Oncology, Washington, University St. Louis, St. Louis, MO, USA
| | - Imran Zoberi
- Siteman Cancer Center, St. Louis, MO, USA
- Department of Radiation Oncology, Washington, University St. Louis, St. Louis, MO, USA
| | - Elizabeth Odom
- Division of Plastic Surgery, Washington, University St. Louis, St. Louis, MO, USA
| | - Jennifer Yu
- Department of Surgery, Section of Endocrine and Oncologic Surgery, Washington University St. Louis, St. Louis, MO, USA
| | - Su-Hsin Chang
- Siteman Cancer Center, St. Louis, MO, USA
- Department of Surgery, Division of Public Health Science, Washington University St. Louis, St. Louis, MO, USA
| | - William E Gillanders
- Department of Surgery, Section of Endocrine and Oncologic Surgery, Washington University St. Louis, St. Louis, MO, USA.
- Siteman Cancer Center, St. Louis, MO, USA.
- Department of Surgery, Washington University School of Medicine, Campus Box 8109, 4590 Children's Place, Suite 9600, St. Louis, MO, 63110, USA.
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16
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Hauerslev KR, Madsen AH, Overgaard J, Damsgaard TE, Christiansen P. Long-term follow-up on shoulder and arm morbidity in patients treated for early breast cancer. Acta Oncol 2020; 59:851-858. [PMID: 32285717 DOI: 10.1080/0284186x.2020.1745269] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Background: A prospective study on shoulder and arm morbidity was conducted in Denmark in 2003-2005. This study demonstrated that sentinel lymph node biopsy was associated with better outcomes than axillary lymph node dissection 18 months after surgery. We here aimed to describe subjective symptoms and objective findings in these patients 10+ years after they underwent breast cancer surgery and to assess how symptoms and findings developed during this period.Material and methods: Participants in the prospective study completed a questionnaire and underwent an objective, bilateral examination of their shoulder and arm morbidity, which included measurement of arm volume, range of motion, and sensibility.Results: Seventy participants completed follow-up. Thirty-four (49%) had one or more functional impairments, and 64% had one or more subjective loco regional symptoms like pain, swelling of the arm, and decreased shoulder mobility. Objective evaluation showed 34 ml's of increased arm volumes and 3-25% had severe reduced shoulder mobility on the operated side. Compared to the findings at 18 months postoperatively, small but significant differences in occurrence of subjective findings were observed. A significant progression regarding most objective findings was revealed.Conclusion: More than 11 years after breast cancer surgery, the majority of participants complained of one or more subjective symptoms of shoulder and arm morbidity. Objective findings were mild or modest in most cases. During the prolonged follow-up period of 10 years, a worsening in symptoms and objective findings was observed.HIGHLIGHTSShoulder and arm morbidity in relation to breast cancer treatment seems to progress beyond 10 years.The most frequent symptoms were pain, swelling or heaviness of the arm, and decreased shoulder mobility.The objective evaluation showed higher arm volumes and reduced shoulder mobility on the operated side.Objective findings are mild and modest but may affect activities of daily living, and most participants with late symptoms stated that this was a daily problem.
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Affiliation(s)
- Katrine Rye Hauerslev
- Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark
| | | | - Jens Overgaard
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Peer Christiansen
- Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark
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17
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Factors associated with professional healthcare advice seeking in breast cancer–related lymphedema. J Surg Oncol 2019; 121:67-74. [DOI: 10.1002/jso.25523] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 05/04/2019] [Indexed: 11/07/2022]
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18
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Manirakiza A, Irakoze L, Shui L, Manirakiza S, Ngendahayo L. Lymphoedema After Breast Cancer Treatment is Associated With Higher Body Mass Index: A Systematic Review and Meta-Analysis. East Afr Health Res J 2019; 3:178-192. [PMID: 34308212 PMCID: PMC8279288 DOI: 10.24248/eahrj-d-19-00009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 10/07/2019] [Indexed: 11/25/2022] Open
Abstract
Background: Excess body weight has been identified as an important risk factor for lymphoedema following breast cancer treatment, however it remains unclear how much risk increases as weight increases. We conducted a meta-analysis to assess the relationship between body mass index (BMI) and risk of lymphoedema in breast cancer patients, and to estimate the level of risk by BMI category. Methods: We conducted a systematic search of all articles published through May 2018 in PubMed and the Cochrane library. Studies that included data on BMI and lymphoedema in breast cancer patients were included in the meta-analysis. We compared risk of lymphoedema in BMI groups as: BMI<25 versus BMI≥25, BMI<25 versus BMI≥30, BMI≥25 to <30 versus BMI≥30, BMI<30 versus BMI≥30, BMI<25 versus BMI≥25 to BMI<30. Results: After exclusion of ineligible studies, 57 studies were included in the meta-analysis. The mean difference in BMI between patients with lymphoedema compared to those without lymphoedema was 1.7 (95% CI, 1.3–2.2). Compared to patients with a BMI<25, risk of lymphoedema was higher in those with a BMI >25 to <30 (odds ratio [OR] 1.3; 95% CI, 1.2 to 1.5), a BMI≥25 (OR 1.7; 95% CI, 1.5 to 1.9), or a BMI≥30 (OR 1.9; 95% CI, 1.6 to 2.4). Compared to patients with a BMI of >25 to <30, risk of lymphoedema was higher in patients with a BMI>30 (OR 1.5; 95% CI,1.4 to 1.8). Conclusion: Excess body weight is a risk factor for lymphoedema following treatment of breast cancer, with the magnitude of risk increasing across higher categories of BMI.
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Affiliation(s)
- Astère Manirakiza
- Department of Oncology, Karuzi Fiftieth Hospital, Karuzi, Burundi.,Department of Oncology, University Hospital Centre of Kamenge, Bujumbura, Burundi
| | - Laurent Irakoze
- Department of Endocrinology, First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Lin Shui
- Department of Oncology, West China Medical Center, Sichuan University, Chengdu, China
| | - Sébastien Manirakiza
- Faculty of Medicine, University of Burundi, Bujumbura, Burundi.,Department of Radiology, University Hospital Centre of Kamenge, Bujumbura, Burundi
| | - Louis Ngendahayo
- Faculty of Medicine, University of Burundi, Bujumbura, Burundi.,Department of Pathology, University Hospital Centre of Kamenge, Bujumbura, Burundi
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19
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Evaluation of distant sequelae of breast cancer treatment among patients after breast-conserving surgery depending on the type of intervention in the axillary fossa. Contemp Oncol (Pozn) 2018; 22:240-246. [PMID: 30783388 PMCID: PMC6377421 DOI: 10.5114/wo.2018.82643] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 11/15/2018] [Indexed: 11/17/2022] Open
Abstract
Aim of the study The goal of this work was to assess upper-limb sequelae among patients undergoing breast-conserving therapy (BCT) for breast cancer 5-6 years after the surgical procedure. Material and methods A controlled clinical study was conducted on 128 patients who had undergone surgery 5-6 years prior. BCT + ALND (axillary lymph node dissection) was performed in 58 patients and 69 underwent BCT + SLND (sentinel lymph node dissection). Patients declared active participation in physiotherapy. The following parameters were assessed in studied subjects: range of motion in the shoulder joint, superficial sensation, upper limb circumference, skin sensation, and presence of winged scapula sign. Results Five to six years after BCT, patients who had undergone BCT + ALND presented with significantly poorer outcomes concerning upper limb range of motion on the operated side compared to the BCT + SLND group with regard to the following features: flexion (p = 0.00004), external rotation (p = 0.0292), and internal rotation (p = 0.0448). However, no statistically significant differences were noted between compared groups with regard to upper limb circumference and sensation disturbances. Statistically significant differences between limb on the operated side (operated limb - OL) vs. contralateral limb (healthy limb - HL) were noted in the BCT + SLND group with regard to the range of motion in extension (p = 0.0004), external rotation (p = 0.0055), and internal rotation (p < 0.0001), as well as the occurrence of winged scapula sign (p < 0.0001) and sensation disturbances (p < 0.0001). Conclusions Our study demonstrated that both procedures are not free of distant sequelae, although the BCT + ALND group is more frequently affected.
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20
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Tsai RJ, Dennis LK, Lynch CF, Snetselaar LG, Zamba GKD, Scott-Conner C. Lymphedema following breast cancer: The importance of surgical methods and obesity. ACTA ACUST UNITED AC 2018; 3. [PMID: 30555923 DOI: 10.15761/fwh.1000144] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background Breast cancer-related arm lymphedema is a serious complication that can adversely affect quality of life. Identifying risk factors that contribute to the development of lymphedema is vital for identifying avenues for prevention. The aim of this study was to examine the association between the development of arm lymphedema and both treatment and personal (e.g., obesity) risk factors. Methods Women diagnosed with breast cancer in Iowa during 2004 and followed through 2010, who met eligibility criteria, were asked to complete a short computer assisted telephone interview about chronic conditions, arm activities, demographics, and lymphedema status. Lymphedema was characterized by a reported physician-diagnosis, a difference between arms in the circumference (> 2cm), or the presence of multiple self-reported arm symptoms (at least two of five major arm symptoms, and at least four total arm symptoms). Relative risks (RR) were estimated using logistic regression. Results Arm lymphedema was identified in 102 of 522 participants (19.5%). Participants treated by both axillary dissection and radiation therapy were more likely to have arm lymphedema than treated by either alone. Women with advanced cancer stage, positive nodes, and larger tumors along with a body mass index > 40 were also more likely to develop lymphedema. Arm activity level was not associated with lymphedema. Conclusions Surgical methods, cancer characteristics and obesity were found to contribute to the development of arm lymphedema. Vigorous arm activity post-surgery was not found to increase the risk of arm lymphedema.
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Affiliation(s)
- Rebecca J Tsai
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - Leslie K Dennis
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA, USA.,Division of Epidemiology and Biostatistics, College of Public Health, University of Arizona, Tucson, AZ, USA
| | - Charles F Lynch
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - Linda G Snetselaar
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - Gideon K D Zamba
- Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - Carol Scott-Conner
- Department of Surgery, College of Medicine, University of Iowa, Iowa City, IA, USA
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21
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Abstract
PURPOSE Approximately 20% of breast cancer survivors develop breast cancer-related lymphedema (BCRL), and current therapies are limited. We compared acupuncture (AC) to usual care wait-list control (WL) for treatment of persistent BCRL. METHODS Women with moderate BCRL lasting greater than six months were randomized to AC or WL. AC included twice weekly manual acupuncture over six weeks. We evaluated the difference in circumference and bioimpedance between affected and unaffected arms. Responders were defined as having a decrease in arm circumference difference greater than 30% from baseline. We used analysis of covariance for circumference and bioimpedance measurements and Fisher's exact to determine the proportion of responders. RESULTS Among 82 patients, 73 (89%) were evaluable for the primary endpoint (36 in AC, 37 in WL). 79 (96%) patients received lymphedema treatment before enrolling in our study; 67 (82%) underwent ongoing treatment during the trial. We found no significant difference between groups for arm circumference difference (0.38 cm greater reduction in AC vs. WL, 95% CI - 0.12 to 0.89, p = 0.14) or bioimpedance difference (1.06 greater reduction in AC vs. WL, 95% CI - 5.72 to 7.85, p = 0.8). There was also no difference in the proportion of responders: 17% AC versus 11% WL (6% difference, 95% CI - 10 to 22%, p = 0.5). No severe adverse events were reported. CONCLUSIONS Our acupuncture protocol appeared to be safe and well tolerated. However, it did not significantly reduce BCRL in pretreated patients receiving concurrent lymphedema treatment. This regimen does not improve upon conventional lymphedema treatment for breast cancer survivors with persistent BCRL.
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22
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Ribeiro Pereira ACP, Koifman RJ, Bergmann A. Incidence and risk factors of lymphedema after breast cancer treatment: 10 years of follow-up. Breast 2017; 36:67-73. [PMID: 28992556 DOI: 10.1016/j.breast.2017.09.006] [Citation(s) in RCA: 123] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 09/21/2017] [Accepted: 09/27/2017] [Indexed: 11/30/2022] Open
Abstract
PURPOSE To evaluate the incidence and risk factors of lymphedema 10 years after surgical treatment for breast cancer. METHODS Prospective observational hospital-based cohort of women undergoing axillary lymph node dissection. Lymphedema was assessed by indirect volume, measured by circumference, and diagnosed if there was a difference of 200 mL between the arms or if the patient was treated for it. Independent variables were patient, tumour and treatment characteristics. Descriptive statistics were conducted as survival analysis using the Kaplan-Meier estimate. Cox regression was performed, considering a 95% confidence interval (95%CI). RESULTS The study evaluated 964 women. The cumulative incidence of lymphedema observed was 13.5% at two years of follow-up, 30.2% at five years and 41.1% at 10 years. Final model showed an increased risk for lymphedema among women that underwent radiotherapy (HR = 2.19; 95%CI 1.63-2.94), were obese (HR = 1.52; 95%CI 1.20-1.92), had seroma formation after surgery (HR = 1.46; 95%CI 1.14-1.87), underwent chemotherapy infusion in the affected limb (HR = 1.45; 95%CI 1.12-1.87) or advanced disease staging (HR = 1.41; 95%CI 1.11-1.80). CONCLUSIONS Cumulative incidence of lymphedema was 41.1%. Women undergoing axillary radiotherapy, obese, who developed seroma, underwent chemotherapy infusion in the affected limb and with advanced disease had a higher risk of lymphedema.
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23
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Wang H, Shen L, Liu T, Shao P, Dylke ES, Jia J, Kilbreath SL. Circumference-Based Criteria for Detection of Secondary Arm Lymphedema for Chinese Women. Lymphat Res Biol 2017; 15:262-267. [PMID: 28749717 DOI: 10.1089/lrb.2017.0002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Hewei Wang
- Rehabilitation Department, Huanshan Hospital, Fudan University, Shanghai, China
| | - Li Shen
- Rehabilitation Department, Huanshan Hospital, Fudan University, Shanghai, China
| | - Tao Liu
- Ma Qiao Community Health Service Center, Shanghai, China
| | - Peng Shao
- Rehabilitation Department, Huanshan Hospital, Fudan University, Shanghai, China
| | | | - Jie Jia
- Rehabilitation Department, Huanshan Hospital, Fudan University, Shanghai, China
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24
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De-escalation of axillary surgery in early breast cancer. Lancet Oncol 2017; 17:e430-e441. [PMID: 27733269 DOI: 10.1016/s1470-2045(16)30311-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 07/05/2016] [Accepted: 07/08/2016] [Indexed: 12/15/2022]
Abstract
With the advent of sentinel lymph node biopsy, surgical methods for accurately staging the axilla in patients with early-stage breast cancer have become progressively less extensive, with formal axillary lymph node dissection confined to a dwindling group of patients. Although details of methods for sentinel lymph node biopsy have yet to be standardised, this technique is now widely practised and accepted as standard of care worldwide. In the past 5 years, attention has focused on minimisation of surgical morbidity by restricting further axillary surgery or considering radiotherapy in patients with a small tumour burden in their sentinel nodes. This change in approach to patients with positive sentinel lymph node biopsies has increased the complexity of axillary management, and any policy of de-escalation and avoidance of morbidity must not compromise patient outcomes. This trend for de-escalation has accompanied a shift in understanding of how any residual tumour burden can be adequately managed without surgical extirpation and reliance on effective adjuvant therapies. Indications for omission of completion axillary lymph node dissection in patients with two or fewer nodes containing macrometastases demand further clarification, together with the roles of preoperative imaging in defining axillary nodal burden, deselection of patients for sentinel lymph node biopsy, and provision of radiotherapy. Downstaging of biopsy-proven node-positive patients with neoadjuvant chemotherapy could safely permit sentinel lymph node biopsy alone when the index node has been successfully retrieved at surgery, while nodal deposits of any size continue to mandate completion axillary lymph node dissection. Developments in molecular imaging technologies and percutaneous biopsy techniques could potentially render sentinel lymph node biopsy redundant in the future.
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25
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Collins M, O'Donoghue C, Sun W, Zhou JM, Ma Z, Laronga C, Lee MC. Use of axillary lymph node dissection (ALND) in patients with micrometastatic breast cancer. J Surg Res 2017; 215:55-59. [PMID: 28688661 DOI: 10.1016/j.jss.2017.03.039] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 02/08/2017] [Accepted: 03/24/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Sentinel lymph node (SLN) biopsy is the current prognostic tool for clinically node-negative breast cancer patients. If the SLN reveals macrometastasis, axillary lymph node dissection (ALND) is recommended. However, the use of ALND in patients with micrometastasis is debated. The objective of this study was to assess the utilization of ALND in the treatment of micrometastatic breast cancer. METHODS An IRB approved, retrospective study of a pooled dataset of breast cancer patients with micrometastatic disease on SLN biopsy was performed. Patients diagnosed from 1999-2016 were identified via query of a single-institution National Comprehensive Cancer Network (NCCN) breast cancer database as well as a prospective tumor board. RESULTS A total of 91 patients were diagnosed with micrometastatic nodal disease. The median age at diagnosis was 56 y (range: 31-85); median follow-up time was 47 mo (range: 0-203 mo). 42/91(46.2%) patients had ALND of which 37/42 (88.1%) were a second operation; 3/42(7.1%) patients had additional positive nodes found at ALND. 44/91 (48.4%) patients received radiation. 7/91 (7.7%) patients had a recurrence, 5/7 local, including one axillary (2.1%; patient declined ALND). CONCLUSIONS Given that the risk of lymphedema after ALND ranges between 20%-53%, the morbidity of ALND may far exceed the likelihood of detecting further nodal involvement in women with micrometastatic disease: 7.1% in this series.
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Affiliation(s)
- Madison Collins
- University of South Florida Morsani College of Medicine, Tampa Florida
| | - Cristina O'Donoghue
- Comprehensive Breast Program, Moffitt Cancer Center, Tampa, Florida; Department of Surgery, University of South Florida, Tampa, Florida
| | - Weihong Sun
- Comprehensive Breast Program, Moffitt Cancer Center, Tampa, Florida; Department of Surgery, University of South Florida, Tampa, Florida
| | - Jun-Min Zhou
- Department of Biostatistics, Moffitt Cancer Center and Research Institute Tampa, Florida
| | - Zhenjun Ma
- Department of Biostatistics, Moffitt Cancer Center and Research Institute Tampa, Florida
| | - Christine Laronga
- Comprehensive Breast Program, Moffitt Cancer Center, Tampa, Florida; Department of Surgery, University of South Florida, Tampa, Florida
| | - Marie Catherine Lee
- Comprehensive Breast Program, Moffitt Cancer Center, Tampa, Florida; Department of Surgery, University of South Florida, Tampa, Florida.
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26
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Iyigun ZE, Duymaz T, Ilgun AS, Alco G, Ordu C, Sarsenov D, Aydin AE, Celebi FE, Izci F, Eralp Y, Ozmen V. Preoperative Lymphedema-Related Risk Factors in Early-Stage Breast Cancer. Lymphat Res Biol 2017; 16:28-35. [PMID: 28346852 DOI: 10.1089/lrb.2016.0045] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Prolongation of survival in patients with breast cancer due to early diagnosis and modern methods of treatment has turned the attention on lymphedema, which is the most important morbidity secondary to the treatment of the disease. Determination of lymphedema and related risk factors in patients before a surgical intervention may provide protection for patients and early treatment. The aim of this study was to determine the presence of lymphedema before surgery by bioimpedance analysis in patients with breast cancer and to establish risk factors associated with lymphedema. PATIENTS AND METHODS A total of 277 patients who were diagnosed as having breast cancer, were planned to undergo a surgical intervention, and had no clinical lymphedema were included in the study. The presence of lymphedema was evaluated with clinical examination, measurement of arm circumference, and bioimpedance analysis. RESULTS Lymphedema was found in 59 (21.3%) patients with no detected differences in arm circumferences. A significant relationship was found between the presence of lymphedema and body mass index (BMI), number of positive lymph nodes, and capsule invasion of the tumor (p = 0.001, p = 0.003, p = 0.002, respectively). Multiple regression analysis revealed that BMI and the number of positive lymph nodes were independent variables (p = 0.024, p = 0.002). ROC curve analysis resulted in an increased risk of preoperative lymphedema when the number of positive lymph nodes was ≥8. Correlation analysis revealed a positive correlation between the number of positive lymph nodes and L-dex score (p = 0.001, r = 0.219). CONCLUSION Preoperative bioimpedance analysis demonstrated that ∼1/5 of the patients had subclinical lymphedema. Preoperative subclinical lymphedema is associated with obesity and the number of positive lymph nodes, and thus, treatment of the axilla in patients who are preoperatively detected to have subclinical lymphedema should be revised.
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Affiliation(s)
- Zeynep Erdogan Iyigun
- 1 Department of Physical Theraphy and Rehabilitation, Istanbul Bilim University School of Medicine , Istanbul, Turkey
| | - Tomris Duymaz
- 1 Department of Physical Theraphy and Rehabilitation, Istanbul Bilim University School of Medicine , Istanbul, Turkey
| | - Ahmet Serkan Ilgun
- 2 Department of General Surgery, Gaziosmanpaşa Taksim Training and Research Hospital , Istanbul, Turkey
| | - Gul Alco
- 3 Department of Radiation Oncology, Gayrettepe Florence Nightingale Hospital , Istanbul, Turkey
| | - Cetin Ordu
- 4 Department of Medical Oncology, Gayrettepe Florence Nightingale Hospital , Istanbul, Turkey
| | - Dauren Sarsenov
- 5 Department of Breast Surgery, Istanbul Florence Nightingale Hospital , Istanbul, Turkey
| | - Ayse Esra Aydin
- 5 Department of Breast Surgery, Istanbul Florence Nightingale Hospital , Istanbul, Turkey
| | - Filiz Elbuken Celebi
- 6 Department of Radiology, Gayrettepe Florence Nightingale Hospital , Istanbul, Turkey
| | - Filiz Izci
- 7 Department of Psychiatry, Istanbul Bilim University School of Medicine , Istanbul, Turkey
| | - Yeşim Eralp
- 8 Department of Medical Oncology, Oncology Institute, Istanbul University , Istanbul, Turkey
| | - Vahit Ozmen
- 9 Department of Breast Surgery, Istanbul University Istanbul Medical Faculty , Istanbul, Turkey
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Risk factors for lymphoedema in women with breast cancer: A large prospective cohort. Breast 2016; 28:29-36. [DOI: 10.1016/j.breast.2016.04.011] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Revised: 04/18/2016] [Accepted: 04/24/2016] [Indexed: 12/15/2022] Open
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Gass J, Dupree B, Pruthi S, Radford D, Wapnir I, Antoszewska R, Curtis A, Johnson N. Breast Cancer Survivorship: Why, What and When? Ann Surg Oncol 2016; 23:3162-7. [DOI: 10.1245/s10434-016-5403-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Indexed: 11/18/2022]
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Immediate Implant Reconstruction Is Associated With a Reduced Risk of Lymphedema Compared to Mastectomy Alone: A Prospective Cohort Study. Ann Surg 2016; 263:399-405. [PMID: 25607768 DOI: 10.1097/sla.0000000000001128] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE We sought to determine the risk of lymphedema associated with immediate breast reconstruction compared to mastectomy alone. BACKGROUND Immediate breast reconstruction is increasingly performed at the time of mastectomy. Few studies have examined whether breast reconstruction impacts development of lymphedema. METHODS A total of 616 patients with breast cancer who underwent 891 mastectomies between 2005 and 2013 were prospectively screened for lymphedema at our institution, with 22.2 months' median follow-up. Mastectomies were categorized as immediate implant, immediate autologous, or no reconstruction. Arm measurements were performed preoperatively and during postoperative follow-up using a Perometer. Lymphedema was defined as 10% or more arm volume increase compared to preoperative. Kaplan-Meier and Cox regression analyses were performed to determine lymphedema rates and risk factors. RESULTS Of 891 mastectomies, 65% (580/891) had immediate implant, 11% (101/891) immediate autologous, and 24% (210/891) no reconstruction. The two-year cumulative incidence of lymphedema was as follows: 4.08% [95% confidence interval (CI): 2.59-6.41%] implant, 9.89% (95% CI: 4.98-19.1%) autologous, and 26.7% (95% CI: 20.4-34.4%) no reconstruction. By multivariate analysis, immediate implant [hazards ratio (HR): 0.352, P < 0.0001] but not autologous (HR: 0.706, P = 0.2151) reconstruction was associated with a significantly reduced risk of lymphedema compared to no reconstruction. Axillary lymph node dissection (P < 0.0001), higher body mass index (P < 0.0001), and greater number of nodes dissected (P = 0.0324) were associated with increased lymphedema risk. CONCLUSIONS This prospective study suggests that in patients for whom implant-based reconstruction is available, immediate implant reconstruction does not increase the risk of lymphedema compared to mastectomy alone.
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Abstract
The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice.A 46-year-old premenopausal woman with a body mass index of 21 was found on screening mammography to have a new, approximately 1-cm spiculated mass with associated calcifications in the upper outer quadrant of the left breast. Stereotactic core biopsy showed a focus of invasive duct carcinoma, strongly positive for estrogen and progesterone receptors and negative for human epidermal growth factor receptor 2, with associated ductal carcinoma in situ. Clinical examination revealed no palpable mass or axillary lymphadenopathy. She underwent a left lumpectomy with seed localization and sentinel lymph node biopsy. Final pathology revealed an 8-mm well-differentiated invasive carcinoma without lymphovascular invasion and intermediate grade ductal carcinoma in situ. The margins were clear, and three sentinel lymph nodes were negative for metastasis. The 21-gene recurrence score was 10, suggesting a 7% risk of 10-year distant recurrence with adjuvant endocrine treatment. After the completion of adjuvant radiotherapy (42.50 Gy in 16 fractions to the breast), the patient has returned for a follow-up visit. She is a professional violinist and would like to know what she can do to prevent lymphedema on her upcoming flight to Vienna.
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Affiliation(s)
- Soojin Ahn
- Mount Sinai Medical Center, New York, NY
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Yamazaki H, Todo Y, Takeshita S, Ohba Y, Sudo S, Minobe S, Okamoto K, Yamashiro K, Kato H. Relationship between removal of circumflex iliac nodes distal to the external iliac nodes and postoperative lower-extremity lymphedema in uterine cervical cancer. Gynecol Oncol 2015; 139:295-9. [DOI: 10.1016/j.ygyno.2015.09.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 09/01/2015] [Accepted: 09/06/2015] [Indexed: 11/25/2022]
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Kondo T, Hayashi N, Ohde S, Suzuki K, Yoshida A, Yagata H, Niikura N, Iwamoto T, Kida K, Murai M, Takahashi Y, Tsunoda H, Nakamura S, Yamauchi H. A model to predict upstaging to invasive carcinoma in patients preoperatively diagnosed with ductal carcinoma in situ of the breast. J Surg Oncol 2015; 112:476-80. [DOI: 10.1002/jso.24037] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 08/22/2015] [Indexed: 11/08/2022]
Affiliation(s)
- Takafumi Kondo
- Departments of Breast Surgical Oncology; St. Luke's International Hospital; Tokyo Japan
| | - Naoki Hayashi
- Departments of Breast Surgical Oncology; St. Luke's International Hospital; Tokyo Japan
| | - Sachiko Ohde
- St. Luke's Life Science Institute Center for Clinical Epidemiology; Tokyo Japan
| | - Koyu Suzuki
- Departments of Pathology; St. Luke's International Hospital; Tokyo Japan
| | - Atsushi Yoshida
- Departments of Breast Surgical Oncology; St. Luke's International Hospital; Tokyo Japan
| | - Hiroshi Yagata
- Departments of Breast Surgical Oncology; St. Luke's International Hospital; Tokyo Japan
| | - Naoki Niikura
- Departments of Breast and Endocrine Surgery; Tokai University School of Medicine; Kanagawa Japan
| | - Takayuki Iwamoto
- Department of Gastroenterological Surgery and Surgical Oncology; Okayama University; Okayama Japan
| | - Kumiko Kida
- Departments of Breast Surgical Oncology; St. Luke's International Hospital; Tokyo Japan
| | - Michiko Murai
- Departments of Breast Surgical Oncology; St. Luke's International Hospital; Tokyo Japan
| | - Yuko Takahashi
- Departments of Breast Surgical Oncology; St. Luke's International Hospital; Tokyo Japan
| | - Hiroko Tsunoda
- Departments of Radiology; St. Luke's International Hospital; Tokyo Japan
| | - Seigo Nakamura
- Department of Surgery; Division of Breast Surgical Oncology; Showa University School of Medicine; Tokyo Japan
| | - Hideko Yamauchi
- Departments of Breast Surgical Oncology; St. Luke's International Hospital; Tokyo Japan
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Patterns of Obesity and Lymph Fluid Level during the First Year of Breast Cancer Treatment: A Prospective Study. J Pers Med 2015; 5:326-40. [PMID: 26404383 PMCID: PMC4600151 DOI: 10.3390/jpm5030326] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 08/06/2015] [Accepted: 08/21/2015] [Indexed: 01/01/2023] Open
Abstract
Obesity is one of the risk factors for developing lymphedema following breast cancer treatment. We prospectively enrolled 140 women and followed the participants for 12 months after surgery to investigate patterns of obesity and lymph fluid level in the first year of cancer treatment. Electrical bioimpedance devices were used to measure weight, BMI, and percent of body fat as well as lymph fluid level. General instructions were given to the participants on maintaining pre-surgery weight. Among the 140 participants, 136 completed the study with 2.9% attrition. More than 60% of the participants were obese (30.8%) or overweight (32.4%), while only two participants were underweight and about 35% had normal weight. This pattern of obesity and overweight was consistent at 4–8 weeks and 12 months post-surgery. At 12 months post-surgery, the majority of the women (72.1%) maintained pre-surgery weight and 15.4% had >5% weight loss; 12.5% of the women increase >5% of their weight. Significantly more patients in the obesity group had lymphedema defined by L-Dex ratio >7.1 than those in the normal/underweight and overweight group at pre-surgery and 4–8 weeks post-surgery. There was a trend of more patients in the obesity group had L-Dex ratio >7.1 at 12 months post-surgery. Obesity and overweight remain among women at the time of cancer diagnosis and the patterns of obesity and overweight continue during the first year of treatment. General instructions on having nutrition-balanced and portion-appropriate diet and physical activities daily or weekly can be effective to maintain pre-surgery weight.
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Prevalence, Classification, and Risk Factors for Postoperative Lower Extremity Lymphedema in Women With Gynecologic Malignancies: A Retrospective Study. Int J Gynecol Cancer 2015; 25:751-7. [DOI: 10.1097/igc.0000000000000405] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ObjectiveLower extremity lymphedema (LEL) is a major long-term complication of radical surgery. We aimed to estimate the incidence and grading of LEL in women who underwent lymphadenectomy and to evaluate risk factors associated with LEL.Materials and MethodsWe retrospectively reviewed 358 patients with cervical, endometrial, and ovarian cancer who underwent transabdominal complete systematic pelvic and para-aortic lymphadenectomy between 1997 and 2011. Lower extremity lymphedema was graded according to criteria of the International Society of Lymphology. Incidence of LEL and its correlation with various clinical characteristics were investigated using Kaplan-Meier survival and Cox proportional hazards methods.ResultsOverall incidence of LEL was 21.8% (stage 1, 60%; stage 2, 32%; and stage 3, 8%). Cumulative incidence increased with observation period: 12.9% at 1 year, 20.3% at 5 years, and 25.4% at 10 years. Age, cancer type, stage (International Federation of Gynecology and Obstetrics), body mass index, hysterectomy type, lymphocyst formation, lymph node metastasis, and chemotherapy were not associated with LEL. Multivariate analysis confirmed that removal of circumflex iliac lymph nodes (hazard ratio [HR], 4.28; 95% confidence interval [CI], 2.09–8.77; P < 0.0001), cellulitis (HR, 3.48; 95% CI, 2.03–5.98; P < 0.0001), and number of removed lymph nodes (HR, 0.99; 95% CI, 0.98–0.99; P = 0.038) were independent risk factors for LEL.ConclusionsPostoperative LEL incidence increased over time. The results of the present study showed a significant correlation with removal of circumflex iliac lymph nodes and cellulitis with the incidence of LEL. Multicenter or prospective studies are required to clarify treatment efficacies.
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Merchant SJ, Chen SL. Prevention and management of lymphedema after breast cancer treatment. Breast J 2015; 21:276-84. [PMID: 25772311 DOI: 10.1111/tbj.12391] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Lymphedema of the arm after breast cancer treatment continues to challenge clinicians worldwide. In this review, we examine the main modalities, both nonsurgical and surgical, to prevent and treat this as yet incurable condition.
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Affiliation(s)
- Shaila J Merchant
- Division of Surgical Oncology, City of Hope National Medical Center, Duarte, California
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Stuiver MM, ten Tusscher MR, Agasi‐Idenburg CS, Lucas C, Aaronson NK, Bossuyt PMM. Conservative interventions for preventing clinically detectable upper-limb lymphoedema in patients who are at risk of developing lymphoedema after breast cancer therapy. Cochrane Database Syst Rev 2015; 2015:CD009765. [PMID: 25677413 PMCID: PMC10651942 DOI: 10.1002/14651858.cd009765.pub2] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Breast cancer-related lymphoedema can be a debilitating long-term sequela of breast cancer treatment. Several studies have investigated the effectiveness of different treatment strategies to reduce the risk of breast cancer-related lymphoedema. OBJECTIVES To assess the effects of conservative (non-surgical and non-pharmacological) interventions for preventing clinically-detectable upper-limb lymphoedema after breast cancer treatment. SEARCH METHODS We searched the Cochrane Breast Cancer Group's (CBCG) Specialised Register, CENTRAL, MEDLINE, EMBASE, CINAHL, PEDro, PsycINFO, and the World Health Organization (WHO) International Clinical Trials Registry Platform in May 2013. Reference lists of included trials and other systematic reviews were searched. SELECTION CRITERIA Randomised controlled trials that reported lymphoedema as the primary outcome and compared any conservative intervention to either no intervention or to another conservative intervention. DATA COLLECTION AND ANALYSIS Three authors independently assessed the risk of bias and extracted data. Outcome measures included lymphoedema, infection, range of motion of the shoulder, pain, psychosocial morbidity, level of functioning in activities of daily life (ADL), and health-related quality of life (HRQoL). Where possible, meta-analyses were performed. Risk ratio (RRs) or hazard ratio (HRs) were reported for dichotomous outcomes or lymphoedema incidence, and mean differences (MDs) for range of motion and patient-reported outcomes. MAIN RESULTS Ten trials involving 1205 participants were included. The duration of patient follow-up ranged from 2 days to 2 years after the intervention. Overall, the quality of the evidence generated by these trials was low, due to risk of bias in the included trials and inconsistency in the results. Manual lymph drainageIn total, four studies used manual lymph drainage (MLD) in combination with usual care or other interventions. In one study, lymphoedema incidence was lower in patients receiving MLD and usual care (consisting of standard education or exercise, or both) compared to usual care alone. A second study reported no difference in lymphoedema incidence when MLD was combined with physiotherapy and education compared to physiotherapy alone. Two other studies combining MLD with compression and scar massage or exercise observed a reduction in lymphoedema incidence compared to education only, although this was not significant in one of the studies. Two out of the four studies reported on shoulder mobility where MLD combined with exercise gave better shoulder mobility for lateral arm movement (shoulder abduction) and forward flexion in the first weeks after breast cancer surgery, compared to education only (mean difference for abduction 22°; 95% confidence interval (CI) 14 to 30; mean difference for forward flexion 14°; 95% CI 7 to 22). Two of the studies on MLD reported on pain, with inconsistent results. Results on HRQoL in two studies on MLD were also contradictory. Exercise: early versus delayed start of shoulder mobilising exercisesThree studies examined early versus late start of postoperative shoulder exercises. The pooled relative risk of lymphoedema after an early start of exercises was 1.69 (95% CI 0.94 to 3.01, 3 studies, 378 participants). Shoulder forward flexion was better at one and six months follow-up for participants who started early with mobilisation exercises compared to a delayed start (two studies), but no meta-analysis could be performed due to statistical heterogeneity. There was no difference in shoulder mobility or self-reported shoulder disability at 12 months follow-up (one study). One study evaluated HRQoL and reported difference at one year follow-up (mean difference 1.6 points, 95% CI -2.14 to 5.34, on the Trial Outcome Index of the FACT-B). Two studies collected data on wound drainage volumes and only one study reported higher wound drainage volumes in the early exercise group. Exercise: resistance trainingTwo studies compared progressive resistance training to restricted activity. Resistance training after breast cancer treatment did not increase the risk of developing lymphoedema (RR 0.58; 95% CI 0.30 to 1.13, two studies, 358 participants) provided that symptoms are monitored and treated immediately if they occur. One out of the two studies measured pain where participants in the resistance training group reported pain more often at three months and six months compared to the control group. One study reported HRQoL and found no significant difference between the groups. Patient education, monitoring and early interventionOne study investigated the effects of a comprehensive outpatient follow-up programme, consisting of patient education, exercise, monitoring of lymphoedema symptoms and early intervention for lymphoedema, compared to education alone. Lymphoedema incidence was lower in the comprehensive outpatient follow-up programme (at any time point) compared to education alone (65 people). Participants in the outpatient follow-up programme had a significantly faster recovery of shoulder abduction compared to the education alone group. AUTHORS' CONCLUSIONS Based on the current available evidence, we cannot draw firm conclusions about the effectiveness of interventions containing MLD. The evidence does not indicate a higher risk of lymphoedema when starting shoulder-mobilising exercises early after surgery compared to a delayed start (i.e. seven days after surgery). Shoulder mobility (that is, lateral arm movements and forward flexion) is better in the short term when starting shoulder exercises earlier compared to later. The evidence suggests that progressive resistance exercise therapy does not increase the risk of developing lymphoedema, provided that symptoms are closely monitored and adequately treated if they occur.Given the degree of heterogeneity encountered, limited precision, and the risk of bias across the included studies, the results of this review should be interpreted with caution.
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Affiliation(s)
- Martijn M Stuiver
- The Netherlands Cancer Institute ‐ Antoni van Leeuwenhoek HospitalDepartment of PhysiotherapyPlesmanlaan 121AmsterdamNetherlands1066CX
- Academic Medical Centre, University of AmsterdamDepartment of Clinical Epidemiology, Biostatistics and BioinformaticsTafelbergweg 51, Roomnr. D223AmsterdamNetherlands
| | - Marieke R ten Tusscher
- The Netherlands Cancer Institute ‐ Antoni van Leeuwenhoek HospitalDepartment of PhysiotherapyPlesmanlaan 121AmsterdamNetherlands1066CX
| | - Carla S Agasi‐Idenburg
- The Netherlands Cancer Institute ‐ Antoni van Leeuwenhoek HospitalDepartment of PhysiotherapyPlesmanlaan 121AmsterdamNetherlands1066CX
| | - Cees Lucas
- Academic Medical Centre, University of AmsterdamDepartment of Clinical Epidemiology, Biostatistics and BioinformaticsTafelbergweg 51, Roomnr. D223AmsterdamNetherlands
| | - Neil K Aaronson
- The Netherlands Cancer Institute ‐ Antoni van Leeuwenhoek HospitalDepartment of Psychosocial Research, Division of Psychosocial Research & EpidemiologyPlesmanlaan 121AmsterdamNetherlands1066 CX
| | - Patrick MM Bossuyt
- Academic Medical Center, University of AmsterdamDepartment of Clinical Epidemiology and BiostatisticsRoom J1b‐214, PO Box 22700AmsterdamNetherlands1100 DE
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Gebruers N, Verbelen H, De Vrieze T, Coeck D, Tjalma W. Incidence and time path of lymphedema in sentinel node negative breast cancer patients: a systematic review. Arch Phys Med Rehabil 2015; 96:1131-9. [PMID: 25637862 DOI: 10.1016/j.apmr.2015.01.014] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Revised: 01/14/2015] [Accepted: 01/16/2015] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To systematically assess the incidence/prevalence and time path of lymphedema in patients with sentinel node-negative breast cancer. DATA SOURCES A systematic literature search up to November 2013 was performed using 4 different electronic databases: PubMed, Embase, Cochrane Clinical Trials, and Web of Science. STUDY SELECTION Inclusion criteria were as follows: (1) research studies that included breast cancer patients who were surgically treated using the sentinel lymph node biopsy (SLNB) technique; (2) sentinel node-negative patients; (3) studies that investigated lymphedema as a primary or secondary outcome; (4) data extraction for the incidence or time path of lymphedema was possible; and (5) publication date starting from January 1, 2001. Exclusion criteria were as follows: (1) reviews or case studies; (2) patients who had an SLNB followed by an axillary lymph node dissection (ALND); (3) results of ALND patients and SLNB patients not described separately; and (4) studies not written in English. DATA EXTRACTION After scoring the methodological quality of the selected studies, the crude data concerning the incidence of lymphedema were extracted. Data concerning the time points and the incidence of lymphedema were also extracted. DATA SYNTHESIS Twenty-eight articles were included, representing 9588 SLNB-negative patients. The overall incidence of lymphedema in patients with sentinel node-negative breast cancer ranged from 0% to 63.4%. The studies that have assessed lymphedema at predefined time points, instead of a mean follow-up time, demonstrated an incidence range at ≤3, 6, 12, 18, or >18 months postsurgery of 3.2% to 5%, 2% to 10%, 3% to 63.4%, 6.6% to 7%, and 6.9% to 8.2%, respectively. CONCLUSIONS In SLNB patients, lymphedema is still a problem, mostly occurring 6 to 12 months after surgery. Because of different assessments and criteria, there is a wide range in incidence. Clear definitions of lymphedema are absolutely necessary to tailor therapy.
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Affiliation(s)
- Nick Gebruers
- Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.
| | - Hanne Verbelen
- Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Tessa De Vrieze
- Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Dorith Coeck
- Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Wiebren Tjalma
- Multidisciplinary Breast Clinic, Antwerp University Hospital, Edegem, Belgium; Department of Medicine, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
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Shaitelman SF, Cromwell KD, Rasmussen JC, Stout NL, Armer JM, Lasinski BB, Cormier JN. Recent progress in the treatment and prevention of cancer-related lymphedema. CA Cancer J Clin 2015; 65:55-81. [PMID: 25410402 PMCID: PMC4808814 DOI: 10.3322/caac.21253] [Citation(s) in RCA: 156] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
This article provides an overview of the recent developments in the diagnosis, treatment, and prevention of cancer-related lymphedema. Lymphedema incidence by tumor site is evaluated. Measurement techniques and trends in patient education and treatment are also summarized to include current trends in therapeutic and surgical treatment options as well as longer-term management. Finally, an overview of the policies related to insurance coverage and reimbursement will give the clinician an overview of important trends in the diagnosis, treatment, and management of cancer-related lymphedema.
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Erdogan Iyigun Z, Selamoglu D, Alco G, Pilancı KN, Ordu C, Agacayak F, Elbüken F, Bozdogan A, Ilgun S, Guler Uysal F, Ozmen V. Bioelectrical impedance for detecting and monitoring lymphedema in patients with breast cancer. Preliminary results of the florence nightingale breast study group. Lymphat Res Biol 2014; 13:40-5. [PMID: 25526543 DOI: 10.1089/lrb.2014.0014] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
The aim of this study was to evaluate the efficacy of bioimpedance spectroscopy for the follow-up of patients with lymphedema in Turkey and its benefits in the diagnosis of stage 0, 1, and 2 lymphedema in patients who are under treatment for breast cancer. Thirty-seven female patients with breast cancer who underwent surgical procedures in our Breast Health Centre were followed up for lymphedema using bioimpedance, and clinical measurements were taken for a minimum period of 1 year at 3-month intervals. Patients who had been monitored regularly between November, 2011, and September, 2013, were enrolled to the study. In total, 8 patients developed lymphedema with an overall rate of 21.6%. Among the 8 patients who developed lymphedema, 4 had Stage 2, 1 had Stage 1, and 3 had Stage 0 lymphedema. Stage 0 lymphedema could not be detected with clinical measurements. During the patients' 1-year follow-up period using measurements of bioimpedance, a statistically significant relationship was observed between the occurrence of lymphedema and the disease characteristics. including the number of the extracted and remaining lymph nodes and the region of radiotherapy (p=0.042, p=0.024, p=0.040). Bioimpedance analysis seems to be a practical and reliable method for the early diagnosis of lymphedema. It is believed that regular monitoring of patients in the high-risk group using bioimpedance analyses increases the ability to treat lymphedema.
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Affiliation(s)
- Zeynep Erdogan Iyigun
- 1 Department of Physical Therapy and Rehabilitation and 4Medical Oncology, Istanbul Bilim University , Istanbul, Turkey
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Jammallo LS, Miller CL, Singer M, Horick NK, Skolny MN, Specht MC, O'Toole J, Taghian AG. Impact of body mass index and weight fluctuation on lymphedema risk in patients treated for breast cancer. Breast Cancer Res Treat 2014; 142:59-67. [PMID: 24122390 DOI: 10.1007/s10549-013-2715-7] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Accepted: 09/26/2013] [Indexed: 10/26/2022]
Abstract
Identifying risk factors for lymphedema in patients treated for breast cancer has become increasingly important, given the current lack of standardization surrounding diagnosis and treatment. Reports on the association of body mass index (BMI) and weight change with lymphedema risk are conflicting. We sought to examine the impact of pre-operative BMI and post-treatment weight change on the incidence of lymphedema. From 2005 to 2011, 787 newly diagnosed breast cancer patients underwent prospective arm volume measurements with a Perometer pre- and post-operatively. BMI was calculated from same-day weight and height measurements. Lymphedema was defined as a relative volume change (RVC) of ≥ 10 %. Univariate and multivariate Cox proportional hazards models were used to evaluate the association between lymphedema risk and pre-operative BMI, weight change, and other demographic and treatment factors. By multivariate analysis, a pre-operative BMI ≥ 30 was significantly associated with an increased risk of lymphedema compared to a pre-operative BMI <25 and 25- <30 (p = 0.001 and p = 0.012, respectively). Patients with a pre-operative BMI 25- <30 were not at an increased risk of lymphedema compared to patients with a pre-operative BMI <25 (p = 0.409). Furthermore, a cumulative absolute weight fluctuation of 10 pounds gained/lost per month post-operatively significantly increased risk of lymphedema (HR: 1.97, p = < 0.0001). In conclusion, pre-operative BMI of ≥ 30 is an independent risk factor for lymphedema, whereas a BMI of 25- <30 is not. Large post-operative weight fluctuations also increase risk of lymphedema. Patients with a pre-operative BMI ≥ 30 and those who experience large weight fluctuations during and after treatment for breast cancer should be considered at higher-risk for lymphedema. Close monitoring or early intervention to ensure optimal treatment of the condition may be appropriate for these patients.
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Elliott RM, Shenk RR, Thompson CL, Gilmore HL. Touch preparations for the intraoperative evaluation of sentinel lymph nodes after neoadjuvant therapy have high false-negative rates in patients with breast cancer. Arch Pathol Lab Med 2014; 138:814-8. [PMID: 24878021 DOI: 10.5858/arpa.2013-0281-oa] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT The use of a touch preparation for intraoperative sentinel lymph node diagnosis has become a preferred method of many pathologists because of its reported high sensitivity and rapid turnaround time. However, after neoadjuvant chemotherapy many lymph nodes have significant treatment-related changes that may affect the diagnostic accuracy of the intraoperative evaluation. OBJECTIVE To determine the accuracy of touch preparation for the intraoperative diagnosis of metastatic breast carcinoma in the neoadjuvant setting. DESIGN We reviewed retrospectively the results of intraoperative evaluations for 148 different sentinel lymph nodes from 63 patients who had undergone neoadjuvant chemotherapy for invasive breast cancer at our institution. The intraoperative touch preparation results were compared with the final pathology reports in conjunction with relevant clinical data. RESULTS Use of touch preparation for the evaluation of sentinel lymph nodes intraoperatively after neoadjuvant therapy was associated with a low sensitivity of 38.6% (95% confidence interval [CI], 24.4-54.5) but high specificity of 100% (95% CI, 96.5-100). There was no difference in sensitivity rates between cytopathologists and noncytopathologists in this cohort (P = .40). Patients with invasive lobular carcinoma and those who had a clinically positive axilla before the initiation of neoadjuvant therapy were the most likely to have a false-negative result at surgery. CONCLUSIONS Intraoperative touch preparations should not be used alone for the evaluation of sentinel lymph nodes in the setting of neoadjuvant therapy for breast cancer because of low overall sensitivity.
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Affiliation(s)
- Robin M Elliott
- From the Departments of Pathology (Drs Elliott and Gilmore) Surgery (Dr Shenk), and Family Medicine (Dr Thompson), University Hospitals Case Medical Center and Case Western Reserve University, Cleveland, Ohio
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Monleon S, Murta-Nascimento C, Bascuas I, Macià F, Duarte E, Belmonte R. Lymphedema Predictor Factors after Breast Cancer Surgery: A Survival Analysis. Lymphat Res Biol 2014; 13:268-74. [PMID: 24837643 DOI: 10.1089/lrb.2013.0042] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Factors associated with lymphedema development after breast cancer surgery are not well established. The purpose is to assess the value of patient, disease and treatment-related factors predicting lymphedema development. METHODS AND RESULTS This study included 371 women with primary invasive breast cancer treated surgically between 2005 and 2009 with follow-up until December 2011. At each follow-up visit, both upper limb circumferences were measured at seven points to calculate the upper limb volume. Kaplan-Meier and Cox regression models for survival were applied. By the end of the follow-up period, 33.4% of women (n=124) had developed lymphedema. According to volume, lymphedema at diagnosis was mild in 78.5%, moderate in 19.0%, and severe in 2.5% of them. A 77.4% of lymphedema had enough clinical relevance to be treated. The probability of developing lymphedema within 12, 24, and 36 months post-surgery was 28.7% (95%CI 24.1-34.0%), 34.6% (95%CI 29.5-40.2%), and 38.3% (95%CI 32.8-44.3%), respectively. High stages, axillary lymph node dissection, chemotherapy, radiotherapy, and postoperative seroma were predictors of lymphedema in the bivariate survival analysis. Only axillary lymph node dissection and radiotherapy maintained their significance in the multivariate model. When the analysis was restricted to patients who underwent axillary lymph node dissection, the number of nodes excised did not influence the occurrence of lymphedema. CONCLUSIONS Axillary lymph node dissection and radiotherapy affected lymphedema development. This study provides support that breast cancer patients with such characteristics should be closely monitored, especially during the first year after surgery.
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Affiliation(s)
- Sandra Monleon
- 1 Servei de Medicina Física i Rehabilitació, e Hospital Mar-Esperança Parc de Salut Mar , Barcelona, Spain .,2 Departament de Medicina, Universitat Autònoma de Barcelona . Cerdanyola Del Valles, Barcelona, Spain
| | - Cristiane Murta-Nascimento
- 3 Servei de d'Epidemiologia i Avaluació, Hospital Mar-Esperança Parc de Salut Mar , Barcelona, Spain .,4 Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC) , Spain
| | - Iria Bascuas
- 1 Servei de Medicina Física i Rehabilitació, e Hospital Mar-Esperança Parc de Salut Mar , Barcelona, Spain .,2 Departament de Medicina, Universitat Autònoma de Barcelona . Cerdanyola Del Valles, Barcelona, Spain
| | - Francesc Macià
- 3 Servei de d'Epidemiologia i Avaluació, Hospital Mar-Esperança Parc de Salut Mar , Barcelona, Spain .,4 Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC) , Spain
| | - Esther Duarte
- 1 Servei de Medicina Física i Rehabilitació, e Hospital Mar-Esperança Parc de Salut Mar , Barcelona, Spain .,2 Departament de Medicina, Universitat Autònoma de Barcelona . Cerdanyola Del Valles, Barcelona, Spain
| | - Roser Belmonte
- 1 Servei de Medicina Física i Rehabilitació, e Hospital Mar-Esperança Parc de Salut Mar , Barcelona, Spain .,2 Departament de Medicina, Universitat Autònoma de Barcelona . Cerdanyola Del Valles, Barcelona, Spain
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Chin-Lenn L, Mack LA, Temple W, Cherniak W, Quinn RR, Ravani P, Lewin AM, Quan ML. Predictors of Treatment with Mastectomy, Use of Sentinel Lymph Node Biopsy and Upstaging to Invasive Cancer in Patients Diagnosed with Breast Ductal Carcinoma In situ (DCIS) on Core Biopsy. Ann Surg Oncol 2013; 21:66-73. [DOI: 10.1245/s10434-013-3239-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Indexed: 11/18/2022]
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Defining a threshold for intervention in breast cancer-related lymphedema: what level of arm volume increase predicts progression? Breast Cancer Res Treat 2013; 140:485-94. [PMID: 23912961 DOI: 10.1007/s10549-013-2655-2] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Accepted: 07/26/2013] [Indexed: 10/26/2022]
Abstract
The purpose of this study is to evaluate arm volume measurements and clinico-pathologic characteristics of breast cancer patients to define a threshold for intervention in breast cancer-related lymphedema. We prospectively performed arm volume measurements on breast cancer patients using a Perometer. Arm measurements were performed pre- and post-operatively, and change in arm volume was quantified using a relative volume change (RVC) equation. Patient and treatment risk factors were evaluated. Cox proportional hazards models with time-dependent covariates for RVC were used to evaluate whether RVC elevations of ≥3 to <5 % or ≥5 to <10 % occurring ≤3 months or >3 months after surgery were associated with progression to ≥10 % RVC. 1,173 patients met eligibility criteria with a median of 27 months post-operative follow-up. The cumulative incidence of ≥10 % RVC at 24 months was 5.26 % (95 % CI 4.01-6.88 %). By multivariable analysis, a measurement of ≥5 to <10 % RVC occurring >3 months after surgery was significantly associated with an increased risk of progression to ≥10 % RVC (HR 2.97, p < 0.0001), but a measurement of ≥3 to <5 % RVC during the same time period was not statistically significantly associated (HR 1.55, p = 0.10). Other significant risk factors included a measurement ≤3 months after surgery with RVC of ≥3 to <5 % (p = 0.007), ≥5 to <10 % (p < 0.0001), or ≥10 % (p = 0.023), axillary lymph node dissection (ALND) (p < 0.0001), and higher BMI at diagnosis (p = 0.0028). Type of breast surgery, age, number of positive or number of lymph nodes removed, nodal radiation, chemotherapy, and hormonal therapy were not significant (p > 0.05). Breast cancer patients who experience a relative arm volume increase of ≥3 to <5 % occurring >3 months after surgery do not have a statistically significant increase in risk of progression to ≥10 %, a common lymphedema criterion. Our data support utilization of a ≥5 to <10 % threshold for close monitoring or intervention, warranting further assessment. Additional risk factors for progression to ≥10 % include ALND, higher BMI, and post-operative arm volume elevation.
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A Model to Estimate the Risk of Breast Cancer-Related Lymphedema: Combinations of Treatment-Related Factors of the Number of Dissected Axillary Nodes, Adjuvant Chemotherapy, and Radiation Therapy. Int J Radiat Oncol Biol Phys 2013; 86:498-503. [DOI: 10.1016/j.ijrobp.2013.02.018] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Revised: 01/22/2013] [Accepted: 02/15/2013] [Indexed: 11/18/2022]
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O'Toole J, Jammallo LS, Skolny MN, Miller CL, Elliott K, Specht MC, Taghian AG. Lymphedema following treatment for breast cancer: a new approach to an old problem. Crit Rev Oncol Hematol 2013; 88:437-46. [PMID: 23777977 DOI: 10.1016/j.critrevonc.2013.05.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Revised: 03/18/2013] [Accepted: 05/02/2013] [Indexed: 01/18/2023] Open
Abstract
Lymphedema following treatment for breast cancer can be an irreversible condition with a profound negative impact on quality of life. The lack of consensus regarding standard definitions of clinically significant lymphedema and optimal methods of measurement and quantification are unresolved problems. Inconsistencies persist regarding the appropriate timing of intervention and what forms of treatment should be the standard of care. There are reports that early detection and intervention can prevent progression, however,the Level 1 evidence to support this hypothesis has yet to be generated. To assess these controversies, we propose the implementation of a screening program to detect early lymphedema in conjunction with a randomized, prospective trial designed to generate Level 1 evidence regarding the efficacy of early intervention and appropriate treatment strategies. Collaboration among institutions that manage breast cancer patients is essential to establish a standardized approach to lymphedema and to establish guidelines for best practice.
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Affiliation(s)
- Jean O'Toole
- Department of Physical and Occupational Therapy, Massachusetts General Hospital, Boston, MA 02114, United States
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DiSipio T, Rye S, Newman B, Hayes S. Incidence of unilateral arm lymphoedema after breast cancer: a systematic review and meta-analysis. Lancet Oncol 2013; 14:500-15. [PMID: 23540561 DOI: 10.1016/s1470-2045(13)70076-7] [Citation(s) in RCA: 1078] [Impact Index Per Article: 98.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The body of evidence related to breast-cancer-related lymphoedema incidence and risk factors has substantially grown and improved in quality over the past decade. We assessed the incidence of unilateral arm lymphoedema after breast cancer and explored the evidence available for lymphoedema risk factors. METHODS We searched Academic Search Elite, Cumulative Index to Nursing and Allied Health, Cochrane Central Register of Controlled Trials (clinical trials), and Medline for research articles that assessed the incidence or prevalence of, or risk factors for, arm lymphoedema after breast cancer, published between Jan 1, 2000, and June 30, 2012. We extracted incidence data and calculated corresponding exact binomial 95% CIs. We used random effects models to calculate a pooled overall estimate of lymphoedema incidence, with subgroup analyses to assess the effect of different study designs, countries of study origin, diagnostic methods, time since diagnosis, and extent of axillary surgery. We assessed risk factors and collated them into four levels of evidence, depending on consistency of findings and quality and quantity of studies contributing to findings. FINDINGS 72 studies met the inclusion criteria for the assessment of lymphoedema incidence, giving a pooled estimate of 16.6% (95% CI 13.6-20.2). Our estimate was 21.4% (14.9-29.8) when restricted to data from prospective cohort studies (30 studies). The incidence of arm lymphoedema seemed to increase up to 2 years after diagnosis or surgery of breast cancer (24 studies with time since diagnosis or surgery of 12 to <24 months; 18.9%, 14.2-24.7), was highest when assessed by more than one diagnostic method (nine studies; 28.2%, 11.8-53.5), and was about four times higher in women who had an axillary-lymph-node dissection (18 studies; 19.9%, 13.5-28.2) than it was in those who had sentinel-node biopsy (18 studies; 5.6%, 6.1-7.9). 29 studies met the inclusion criteria for the assessment of risk factors. Risk factors that had a strong level of evidence were extensive surgery (ie, axillary-lymph-node dissection, greater number of lymph nodes dissected, mastectomy) and being overweight or obese. INTERPRETATION Our findings suggest that more than one in five women who survive breast cancer will develop arm lymphoedema. A clear need exists for improved understanding of contributing risk factors, as well as of prevention and management strategies to reduce the individual and public health burden of this disabling and distressing disorder. FUNDING The National Breast Cancer Foundation, Australia.
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Affiliation(s)
- Tracey DiSipio
- School of Public Health and Social Work, Institute of Health and Biomedical Innovation, Queensland University of Technology, Queensland, Australia.
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Delpech Y, Bricou A, Lousquy R, Hudry D, Jankowski C, Willecocq C, Thoury A, Loustalot C, Coutant C, Barranger E. The Exportability of the ACOSOG Z0011 Criteria for Omitting Axillary Lymph Node Dissection After Positive Sentinel Lymph Node Biopsy Findings: A Multicenter Study. Ann Surg Oncol 2013; 20:2556-61. [DOI: 10.1245/s10434-013-2917-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Indexed: 11/18/2022]
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Intercostobrachial nerves as a novel anatomic landmark for dividing the axillary space in lymph node dissection. ISRN ONCOLOGY 2013; 2013:279013. [PMID: 23401796 PMCID: PMC3563178 DOI: 10.1155/2013/279013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Accepted: 12/16/2012] [Indexed: 11/17/2022]
Abstract
Purpose. Our aim was to assess the feasibility of using the intercostobrachial nerves (ICBNs) as a possible new anatomic landmark for axillaries lymph node dissection in breast cancer patients. Background Data Summary. The preservation of ICBN is now an accepted procedure in this type of dissection; however, it could be improved further to reduce the number of postoperative complications. The axillary space is divided into lower and upper parts by the ICBN-a thorough investigation of the metastasis patterns in lymph nodes found in this area could supply new information leading to such improvements. Methods. Seventy-two breast cancer patients, all about to undergo lymph node dissection and with sentinel lymph nodes identified, were included in this trial. The lymph nodes were collected in two groups, from lower and upper axillary spaces, relative to the intercostobrachial nerves. The first group was further subdivided into sentinel (SLN) and nonsentinel (non-SLN) nodes. All lymph nodes were tested to detect macro- and micrometastasis. Results. All the sentinel lymph nodes were found under the intercostobrachial nerves; more than 10 lymph nodes were located in that space. Moreover, when lymph nodes macrometastasize or micrometastasize above the intercostobrachial nerves, we also observe metastasis-positive nodes under the nerves; when the lower group nodes show no metastasis, the upper group is also metastasis free. Conclusions. Our results show that the intercostobrachial nerves are good candidates for a new anatomic landmark to be used in lymph node dissection procedure.
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Risk factors associated with breast cancer-related lymphedema in the WHEL Study. J Cancer Surviv 2012; 7:115-23. [PMID: 23212606 DOI: 10.1007/s11764-012-0251-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Accepted: 10/19/2012] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Lymphedema is a significant health problem faced by a large percentage of breast cancer survivors. The Women's Healthy Eating and Living (WHEL) Study has a unique dataset collected after the completion of breast cancer treatment, which allowed a focused analysis of risk factors for breast cancer-related lymphedema. METHODS Participant characteristics, treatment modalities, and health behaviors were examined as potential predictors of lymphedema among breast cancer survivors with univariate analyses and multivariate logistic regression. RESULTS Lymphedema status was assessed for 83 % of the study cohort (2,431 of the 2,917 WHEL participants). Among these respondents, 692 (28.5 %) women reported yes to either a physician's diagnosis of lymphedema or a question on arm/hand swelling. When compared to other participants, women with lymphedema were diagnosed at a younger age, more likely to have a higher body mass index, had a larger tumor size, had more lymph nodes removed, more likely to have a mastectomy with radiation therapy, and more likely to have chemotherapy. In the final multivariate-adjusted model, body mass index greater than 25 kg/m(2) (p < 0.01), the removal of 11 or more lymph nodes (p < 0.01), and breast cancer surgery plus radiation therapy (p < 0.01) showed a strong independent association with developing breast cancer-related lymphedema. CONCLUSIONS The results of this study highlight the importance of educating breast cancer survivors about the modifiable risk factors (e.g., body mass index) associated with the development of lymphedema. IMPLICATIONS FOR CANCER SURVIVORS Breast cancer survivors at risk for lymphedema may benefit from interventions aimed at achieving or maintaining a healthy body weight.
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