Morbidity of sentinel node biopsy: relationship between number of excised lymph nodes and patient perceptions of lymphedema

This house believes that: MARI/TAD is better than sentinel node biopsy after PST for cN+ patients

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.

Tailored axillary surgery - A novel concept for clinically node positive breast cancer

Axillary surgery in patients with breast cancer has been a history of de-escalation; however, surgery for clinically node-positive breast cancer remained at the dogmatic level of axillary lymph node dissection (ALND). In these patients, currently the only way to avoid ALND is neoadjuvant systemic treatment (NST) with nodal pathologic complete response (pCR) as diagnosed by selective lymph node removal. However, pCR rates are highly dependent on tumor biology, with luminal tumors being most present yet showing the lowest pCR rates. Therefore, the TAXIS trial is investigating whether in clinically node-positive patients, either with residual disease after NST or in the upfront surgical setting, ALND can be safely omitted. All patients undergo tailored axillary surgery (TAS), which includes removal of the biopsied and clipped node, the sentinel lymph nodes as well as all palpably suspicious nodes, turning a clinically positive axilla into a clinically negative. Feasibility of TAS was recently confirmed in the first pre-specified TAXIS substudy. TAS is followed by axillary radiotherapy to treat any remaining nodal disease. Disease-free survival is the primary endpoint of this non-inferiority trial, and morbidity as well as quality of life are the main secondary endpoints, with ALND being known for having a relevant negative impact on both. Currently, 663 of 1500 patients were randomized; accrual completion is projected for 2025. The TAXIS trial stands out in including clinically node-positive patients in both the neoadjuvant and upfront surgery setting, thereby investigating surgical de-escalation at the far-end of the risk spectrum of patients with breast cancer.

Axillary Staging Is Not Justified in Postmenopausal Clinically Node-Negative Women Based on Nodal Disease Burden

BACKGROUND

RxPONDER showed no benefit of adjuvant chemotherapy in postmenopausal women with estrogen receptor (ER) positive/human epidermal growth factor receptor 2 (HER2) negative breast cancer and limited nodal burden (pN1) with a recurrence score ≤ 25, suggesting that axillary staging could be omitted in cN0 patients if significant numbers of such women do not have pN2-3 disease. Here we evaluate the pN2-3 disease rate in a large cohort of postmenopausal women presenting with cN0 breast cancer.

PATIENTS AND METHODS

Consecutive postmenopausal patients presenting with T1-2N0 breast cancer who underwent axillary surgery from February 2006 to December 2011 were identified. Clinicopathologic characteristics associated with pN2-3 disease were examined using chi-square or Fisher's exact tests.

RESULTS

Of 3363 postmenopausal women with cT1-2N0 breast cancer (median age 58 years, IQR 48-67 years), median tumor size was 1.3 cm (IQR 0.90-1.90cm). Post-axillary staging, 2600 (77.3%) were pN0, 643 (19.1%) were pN1, and 120 (3.6%) were pN2-3. The pN2-3 disease rate did not differ across subtypes (4.4% HER2+, 3.5% HR-/HER2-, 3.5% HR+/HER2-, p = 0.70). In the subset with HR+/HER2- tumors, on multivariable analysis, age < 65 years (odds ratio [OR] 2.38, 95% confidence interval [CI] 1.32-4.49), lymphovascular invasion (OR 5.29, 95% CI 2.72-11.2), multifocal/centric tumors (OR 3.08, 95% CI 1.79-5.32), and tumor size > 2 cm (OR 5.51, 95% CI 3.05-10.4) were significantly associated with pN2-3 nodal burden. Of 506 patients with tumors > 2 cm, 49 (9.7%) had pN2-3 disease; in the subset of 90 patients age < 65 years who had multifocal/centric tumors > 2 cm, 23 (25.6%) had pN2-3 disease.

CONCLUSIONS

In postmenopausal women with cN0 disease, pN2-3 nodal burden is uncommon; omitting axillary staging would not miss a significant number of patients who might benefit from adjuvant chemotherapy. Information available preoperatively indicating a higher risk of nodal disease such as younger age and large, multifocal tumors should be considered in the multidisciplinary management of the axilla.

Sensory signs and symptoms in women with self-reported breast cancer-related lymphedema: a case-control study close up

PURPOSE

It is not clear to what extent signs and symptoms other than arm swelling, including pain, altered sensory function, and body perception disturbances, differ between women with measurable and non-measurable breast cancer-related lymphedema (BCRL). A case-control study was performed to compare these signs and symptoms between (1) women with self-reported BCRL with objectively measurable swelling; (2) women with self-reported BCRL without objective confirmation; and (3) a control group with no self-reported BCRL.

METHODS

The three groups were compared for (1) the severity of self-reported signs and symptoms of BCRL, (2) problems in functioning related to BCRL, (3) pain-related outcomes, (4) sensory functions, and (5) body perception.

RESULTS

All self-reported outcomes related to signs and symptoms of BCRL and problems in functioning were significantly different between the control group and the other two groups with and without measurable self-reported BCRL (p < 0.001-0.003). Except for "skin texture" (p = 0.01), no differences were found between groups. For pain-related outcomes, sensory function, and body perception, significant differences were found for the mechanical detection threshold (p < 0.01) and self-reported disturbances in body perception (p < 0.001) between the self-reported BCRL groups and control group.

CONCLUSIONS

Diverse signs and symptoms related to BCRL, sensory function, and perception were different among women with self-reported BCRL compared to controls. No differences between women with and without measurable self-reported BCRL were found.

IMPLICATIONS FOR CANCER SURVIVORS

The presence of self-reported BCRL, with or without measurable swelling, is a first indication for the need of further diagnostic evaluation.

Lymphedema after Sentinel Lymph Node Biopsy: Who is at Risk?

Aim: Sentinel lymph node biopsy (SLNB) is the accepted approach to stage the clinically negative axilla. The incidence of lymphedema (LE) after SLNB is about 5%. We hypothesize that patients undergoing axillary excision of >5 lymph nodes (LNs) are at increased risk of developing LE. Methods and Results: A single institution prospective breast cancer database was retrospectively reviewed from January 2013 to December 2017, to identify patients who underwent SLNB and were diagnosed with LE. Inclusion criteria was (1) de novo breast cancer, (2) SLNB in clinically node negative patients, and (3) no preoperative diagnosis LE of an extremity. Exclusion criteria was history of axillary lymph node dissection. Age, body mass index, tumor-node-metastasis status, surgery type, neoadjuvant or adjuvant chemotherapy, radiotherapy, and hormone therapy were analyzed. Of the 3325 patients identified, 2940 patients met the inclusion criteria and were included in the final analysis. Median follow-up time was 24 months. Forty-seven (2%) patients were diagnosed with LE, and nine patients (19%) had >5 LNs excised. LE was diagnosed in 3.7% of patients who had >5 LNs excised versus 1.4% of patients with ≤5 LNs excised. Incidence of LE was higher in patients with >5 LNs excision (p = 0.006). Conclusion: Our study showed that patients have a higher likelihood of developing LE when >5 LNs are excised.

Long-term follow-up results of fluorescence and blue dye guided sentinel lymph node biopsy in early breast cancer

PURPOSE

This study aimed to assess the efficacy of the combination of indocyanine green (ICG) and methylene blue (MB) dye in early breast cancer patients undergoing sentinel lymph node biopsy (SLNB).

METHODS

Between January 2011 and December 2015, 1061 early breast cancer patients underwent SLNB were included. SLNB was performed for enrolled patients by injection of both ICG and MB. Detection rate, positivity, and number of sentinel lymph nodes (SLNs) by ICG and MB were analysed. Axillary recurrence and arm lymphedema at 5.6-year follow-up were reported.

RESULTS

The combination of ICG and MB resulted in a very high detection rate of 99.6%, the median number of sentinel lymph nodes was 3. A total of 374 histologically confirmed positive SLNs were detected in 237 patients, 96.6% of the positive patients and 94.1% of the positive nodes could be identified by the combination of ICG and MB. After a median follow-up of 5.6 (2-9.3) years, 0.64% of patients with negative SLNs had ipsilateral axillary recurrence, and the incidence of arm lymphedema was 2.1%.

CONCLUSIONS

Although the missing isotope control weakens the interpretation of the findings, the dual tracing modality of ICG and MB, without involvement of radioactive isotopes, was an effective method for SLNB in patients with early breast cancer.

TRIAL REGISTRATION

ACTRN12612000109808. Registered on 23 January 2012.

Sex Hormones in Lymphedema

Simple Summary

Lymphedema is a life-long disease that affects a large number of patients treated for breast-, gynecological-, and urologic cancers in Western countries. Given that hormone levels are strongly modified in these conditions, and that patients widely undergo through hormone therapy, it is tempting to speculate that hormones might be key regulators in the maintenance of lymphedema. Despite an obvious prevalence for women, the role of sex hormones and gender has been poorly investigated in this pathology. This review aims to decipher how sex hormones interact with lymphatic vessels and whether hormone therapy could participate in lymphedema development.

Abstract

Lymphedema is a disorder of the lymphatic vascular system characterized by impaired lymphatic return resulting in swelling of the extremities and accumulation of undrained interstitial fluid/lymph that results in fibrosis and adipose tissue deposition in the limb. Whereas it is clearly established that primary lymphedema is sex-linked with an average ratio of one male for three females, the role of female hormones, in particular estrogens, has been poorly explored. In addition, secondary lymphedema in Western countries affects mainly women who developed the pathology after breast cancer and undergo through hormone therapy up to five years after cancer surgery. Although lymphadenectomy is identified as a trigger factor, the effect of co-morbidities associated to lymphedema remains elusive, in particular, estrogen receptor antagonists or aromatase inhibitors. In addition, the role of sex hormones and gender has been poorly investigated in the etiology of the pathology. Therefore, this review aims to recapitulate the effect of sex hormones on the physiology of the lymphatic system and to investigate whetherhormone therapy could promote a lymphatic dysfunction leading to lymphedema.

Immediate Lymphatic Reconstruction after Axillary Lymphadenectomy: A Single-Institution Early Experience

PURPOSE

Lymphedema is progressive arm swelling from lymphatic dysfunction which can occur in 30% patients undergoing axillary dissection/radiation for breast cancer. Immediate lymphatic reconstruction (ILR) is performed in an attempt decrease the risk of lymphedema in patients undergoing axillary lymph node dissection (ALND). The purpose of this study was to assess the efficacy of ILR in preventing lymphedema rates in ALND patients.

METHODS

An institutional review board-approved retrospective review was performed of all patients who underwent ILR from 2017 to 2019. Patient demographics, comorbidities, operative and pathologic findings, number of LVAs, limb measurements, complications, and follow-up were recorded and analyzed. Student's sample t-test, Fisher's exact test, and ANOVA were used to analyze data; significance was set at p < 0.05.

RESULTS

Thirty-three patients were included in this analysis. Three patients (9.1%) developed persistent lymphedema, and two patients (6.1%) developed transient arm edema that resolved with compression and massage therapy. A significant effect was found for body mass index and the number of lymph nodes taken on the development of lymphedema (p < 0.01).

CONCLUSIONS

The rate of lymphedema in this series was 9.1%, which is an improvement from historical rates of lymphedema. Our findings support ILR as a technique that potentially decreases the incidence of lymphedema after axillary lymphadenectomy. Obesity and number of lymph nodes removed were significant predictive variables for the development of lymphedema following LVA.

Integrating Biological Advances Into the Clinical Management of Breast Cancer Related Lymphedema

Breast cancer-related lymphedema (BCRL) occurs in a significant number of breast cancer survivors as a consequence of the axillary lymphatics' impairment after therapy (mainly axillary surgery and irradiation). Despite the recent achievements in the clinical management of these patients, BCRL is often diagnosed at its occurrence. In most cases, it remains a progressive and irreversible condition, with dramatic consequences in terms of quality of life and on sanitary costs. There are still no validated pre-surgical strategies to identify individuals that harbor an increased risk of BCRL. However, clinical, therapeutic, and tumor-specific traits are recurrent in these patients. Over the past few years, many studies have unraveled the complexity of the molecular and transcriptional events leading to the lymphatic system ontogenesis. Additionally, molecular insights are coming from the study of the germline alterations involved at variable levels in BCRL models. Regrettably, there is a substantial lack of predictive biomarkers for BCRL, given that our knowledge of its molecular milieu remains extremely puzzled. The purposes of this review were (i) to outline the biology underpinning the ontogenesis of the lymphatic system; (ii) to assess the current state of knowledge of the molecular alterations that can be involved in BCRL pathogenesis and progression; (iii) to discuss the present and short-term future perspectives in biomarker-based patients' risk stratification; and (iv) to provide practical information that can be employed to improve the quality of life of these patients.

A retrospective analysis of commonly prescribed medications and the risk of developing breast cancer related lymphedema

Objectives:

Breast cancer related lymphedema (BCRL) is a common complication of current breast cancer treatment modalities, significantly lowering quality of life for these patients and often leading to recurrent infections. Here, based on pre-clinical literature, we aim to retrospectively evaluate the risks of prescribed medications on BCRL development.

Methods:

All post-operative breast cancer patients who received radiotherapy from 2005–2013 at Massachusetts General Hospital and developed lymphedema(n=115) were included in the analysis. Comparable patients without lymphedema(n=230) were randomly selected as control. The following classes of medications were analyzed: NSAIDs, corticosteroids, angiotensin system inhibitors, calcium channel blockers and hormonal therapy. Known risk factors for lymphedema development were included as variables, including BMI, age at diagnosis, type of surgery, number of lymph nodes removed and radiation therapy. Outcomes were BCRL development and lymphedema severity.

Results:

Similarly, to previous studies, we found that an increase in BMI increases the risk of BCRL(p=0.006) and axillary lymph node dissection has a higher risk of developing BCRL compared to sentinel lymph node biopsy(p=0.045). None of the drugs studied increased the risk of BCRL development or lymphedema severity. However, lymphedema severity was positively correlated with the number of lymph nodes removed(p=0.034).

Conclusion:

We found that anti-inflammatory drugs, anti-hypertensive drugs and hormonal therapy taken during the year postoperatively do not increase the risk of BCRL development or lymphedema severity in breast cancer patients. While others have demonstrated that the number of lymph nodes removed during surgery increases the risk of BCRL, we found it also correlates to lymphedema severity.

Postmastectomy upper limb lymphedema: Combined vascularized lymph node transfer and scar release with fat graft expedites surgical and patients' related outcomes. A retrospective comparative study

INTRODUCTION

Lymphedema resulting from breast cancer treatment is a chronic condition that can significantly compromise quality of life. Several works have documented the efficacy of vascularized lymph node flap transfer (VLNT) for the treatment of advanced-stage lymphedema. Given that the axillary scar may contribute to the patient's existing lymphedema, the authors assumed that combining VLNT and scar release with fat graft could be an effective strategy of treatment. The purpose of this study is to compare the efficacy in the reduction of limb circumference and health-related quality of life between a combined strategy, namely, VLN transfer (VLNT) and axillary scar release with fat grafting, and only VLNT for patients affected by postmastectomy upper limb lymphedema. The idea.

MATERIALS AND METHODS

All patients with stage II and III breast cancer-related lymphedema operated between January 2012 and January 2016 were retrospectively identified, and only those treated by combined VLNT and scar release (Group A) or only VLNT (Group B) were included. The outcomes were assessed clinically by limb circumference measurement and radiologically by lymphoscintigraphy. Lymphedema-related quality of life was evaluated preoperatively and at 1 year follow-up through the LYMQOL questionnaire.

RESULTS

Thirty-nine patients met inclusion criteria (Group A = 18; Group B = 21). Mean follow-up was 29 months for Group A and 32 months for Group B. Flap survival rate was 100%, with no donor site morbidity in all patients. A statistically significant difference between the circumference reduction rates (RR) at above elbow level was observed at 3 and 6 months of follow-up comparing the two groups (p<0.00001), with higher values in Group A than in Group B. No significant difference was detected comparing RR values at above and below elbow at 12 and 24 months postoperatively. LYMQOL metrics showed significantly better scores (p<0.0001) in all domains at all follow-up appointments in Group A.

CONCLUSIONS

Patients with postmastectomy upper limb lymphedema can benefit from combined lymph node transfer and axillary scar release with fat graft, as this approach seems to fasten the onset of improvement and to have a positive impact on patients' quality of life.

Breast Cancer Systemic Treatments and Upper Limb Lymphedema: A Risk-Assessment Platform Encompassing Tumor-Specific Pathological Features Reveals the Potential Role of Trastuzumab

Breast cancer related lymphedema (BCRL) is frequent but strategies for an individualized risk assessment are lacking. We aimed to define whether tumor-specific pathological features, coupled with clinical and therapeutic data, could help identify patients at risk. Data from 368 patients with node-positive breast cancers were retrospectively collected, including 75 patients with BCRL (0.4⁻25.6 years follow-up). BCRL was assessed during the standard follow-up oncology visits using the circumferential measurement. Clinicopathologic and therapeutic factors associated with BCRL were integrated into a Cox proportional hazards regression model. Lymphovascular invasion (LVI) was more common in BCRL patients (n = 33, 44% vs. n = 85, 29%, p = 0.01), akin extra nodal extension (ENE) of the metastasis (n = 57, 76% vs. n = 180, 61%, p = 0.02). Sentinel lymph node excision without axillary dissection and extra-axillary radiotherapy were BCRL-unrelated. A higher number of BCRL-positive patients were treated with taxane-based chemotherapy with or without trastuzumab, compared to BCRL-negative patients (p < 0.01). Treatment with trastuzumab and/or taxanes, adjusted for systemic infections, laterality, therapy, and pathological features (i.e., LVI and ENE), had a significant impact in BCRL-free survival (p < 0.01). This work offers new insights on BCRL risk stratification, where the integration of clinical, therapeutic, and tumor-specific pathological data suggests a possible role of anti-human epidermal growth factor receptor 2 (HER2) therapy in BCRL pathogenesis.

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

Background:

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

Methods:

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

Results:

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

Conclusion:

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

Tackling the diversity of breast cancer related lymphedema: Perspectives on diagnosis, risk assessment, and clinical management

Breast cancer related lymphedema (BCRL) develops as a consequence of surgical treatment and/or radiation therapy in a significant number of breast cancer patients. The etiology of this condition is multifactorial and has not yet been completely elucidated. Risk factors include high body mass index, radical surgical procedures (i.e. mastectomy and axillary lymph node dissection), number of lymph nodes removed and number of metastatic lymph nodes, as well as nodal radiation, and chemotherapy. However, these predisposing factors explain only partially the BCRL occurrence, suggesting the possible involvement of individual determinants. Despite the implementation of conservative approaches, BCRL still remains in a proportion of cases an incurable and progressive condition with major physical and psychological implications. To date, diagnostic methods and staging systems lack uniformity, leading to a possible underestimation of the real incidence of this condition, decreasing early detection and thus the possibility of an effective treatment. Several preventive and therapeutic options are available, both conservative and surgical, but are not included in a standardized intervention protocol, tailored on patient's specific characteristics. In this review, we provide a comprehensive overview of the current state-of-knowledge of BCRL management, novel advantages in the assessment of pre-operative evaluation and risk prediction and discuss strengths and weaknesses of diagnostic and treatment strategies currently accessible in clinical practice.

Axillary Nodal Evaluation in Elderly Breast Cancer Patients: Potential Effects on Treatment Decisions and Survival

BACKGROUND

Recent studies suggest that surgical lymph node (LN) evaluation may be omitted in select elderly breast cancer patients as it may not influence adjuvant therapy decisions. To evaluate differences in adjuvant therapy receipt and overall survival (OS), we compared clinically node-negative (cN0) elderly patients who did and did not undergo axillary surgery.

METHODS

Patients aged ≥70 years in the National Cancer Database (2004-2014) with cT1-3, cN0 breast cancer were divided into two cohorts-those with surgical LN evaluation (one or more nodes removed) and those without (no nodes removed). Propensity scores were used to match patients based on age, year of diagnosis, tumor grade, cT stage, estrogen receptor status, and Charlson-Deyo comorbidity score. A Cox proportional hazards model was used to estimate the effect of LN surgery on OS.

RESULTS

Overall, 133,778 patients were matched, of whom 102,247 patients (76.4%) underwent nodal surgery. Patients undergoing nodal surgery were more likely to receive chemotherapy (pN1-3: 22.2%; pN0: 5.8%; cN0-no nodal surgery: 2.8%; p < 0.001), radiation (pN1-3: 49.7%; pN0: 47.5%; cN0-no nodal surgery: 26%; p < 0.001), and endocrine therapy (pN1-3: 72%; pN0: 58.5%; cN0-no nodal surgery: 46.5%; p < 0.001). After adjustment for known covariates, patients who did not undergo nodal surgery had a worse OS (hazard ratio 1.66, 95% confidence interval 1.61-1.70).

CONCLUSIONS

For elderly cN0 breast cancer patients, axillary surgery was associated with higher rates of adjuvant therapy and improved OS. A selective approach to omitting nodal surgery should be considered in elderly patients with cN0 breast cancer as axillary staging may influence subsequent treatment decisions and long-term outcomes.

The importance of tattoo pigment in sentinel lymph nodes

BACKGROUND

The presence of pigment in axillary lymph nodes (LN) secondary to migration of tattoo ink can imitate the appearance of a blue sentinel lymph node (SLN) on visual inspection, causing the operator to either miss the true SLN or excise more than is needed.

OBJECTIVE

We present patients with tattoos ipsilateral to an early stage breast cancer who underwent a SLN biopsy.

METHODS

Patients were retrospectively reviewed from medical records and clinicopathologic data was collected. A total of 52 LNs were retrieved from 15 patients for sentinel mapping and 29 of them had tattoo pigmentation on pathologic evaluation.

RESULTS

Of those 29 SLNs, 2 of them (6.9%) were pigmented, but did not contain either blue dye or Tc-99m (pseudopigmented SLN). Two (3.8%) SLNs were positive for metastasis; both of these had either blue dye or Tc99m uptake, and 1 demonstrated tattoo pigment in the node.

CONCLUSIONS

In this cohort of patients with ipsilateral tattoos, removed more LNs lead to unnecessary excision which may important for increasing the risk of arm morbidity from SLN biopsy. However, the presence of tattoo pigment did not interfere with understaging for axillary mapping and it did not effect of pathological identification of SLNs positivity.

The clinical implication of the number of lymph nodes harvested during sentinel lymph node biopsy and its effects on survival outcome in patients with node-negative breast cancer

BACKGROUND

The optimal number of sentinel lymph nodes (SLN) that need to be harvested to achieve favorable survival outcome during a SLN biopsy (SLNB) has not yet been established.

METHODS

Six hundred and thirteen patients with clinically node-negative breast cancer who underwent SLNB were reviewed. Survival outcomes according to the number of total harvested lymph nodes (THLNs), defined as the sum of enumerated SLNs and non-SLNs were analyzed.

RESULTS

Patients with only 1 THLN showed lower recurrence-free survival (RFS) as compared to those with ≥2 THLNs (p = 0.049). In multivariate analysis, only 1 THLN was associated with poor RFS (HR = 2.711; p = 0.029).

CONCLUSIONS

Removing at least 2 lymph nodes during SLNB may be acceptable. Harvesting only 1 lymph node should be undertaken cautiously because of false negative results and increasing the subsequent recurrence rate.

Validation of a breast cancer nomogram to predict lymphedema in a Chinese population

BACKGROUND

Upper arm lymphedema (LE) is a common complication after axillary lymph node dissection (ALND) in breast cancer patients. This retrospective cohort study aimed to validate a published nomogram to predict the risk of LE in the Chinese breast cancer patients.

METHODS

A total of 409 breast cancer patients who underwent breast cancer surgery and ALND (level I and II) were identified. Cox regression analysis was used to identify the risk factors for LE. The nomogram predictive of LE of breast cancer was evaluated by receiver-operating curve analysis, calibration plots, and Kaplan-Meier analysis in our study population.

RESULTS

With a median follow-up of 68 months, the 5-year cumulative incidence of LE was 22.3%. Higher body mass index (hazard ratio [HR] = 1.06, 95% CI: 1.00-1.13), neoadjuvant chemotherapy (HR = 3.76, 95% CI: 2.29-6.20), larger extend of axillary surgery (level I/II/III versus level I/II: HR = 2.39, 95% CI: 1.30-4.37), and radiotherapy (HR = 4.90, 95% CI: 1.90-12.5) were independently associated with LE. The AUC value of the nomogram was 0.706 (95% CI: 0.648-0.752). A high-risk subgroup of patients defined by nomogram had significantly higher cumulative risk of LE than those in the low-risk subgroups (P < 0.01). The calibration plots revealed that the nomogram was well calibrated (Hosmer-Lemeshow test, P = 0.0634).

CONCLUSIONS

The nomogram to predict the risk of LE in breast cancer patients with ALND has been validated to be discriminative and accurate. More studies are needed to evaluate the impact of other factors (lifestyle, behaviors, and so forth) on the performance of the nomogram.

Lymphedema Precautions: Time to Abandon Old Practices?

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.

The long-term risk of upper-extremity lymphedema is two-fold higher in breast cancer patients than in melanoma patients

BACKGROUND AND OBJECTIVES

We assessed the cumulative incidence, symptoms, and risk factors for upper-extremity lymphedema in breast cancer and melanoma patients undergoing sentinel lymph node biopsy or axillary lymph node dissection.

METHODS

Patients were recruited preoperatively (time 0) and assessed at 6, 12, and 18 months postoperatively. Limb volume change (LVC) was measured by perometry. Lymphedema was categorized as none, mild (LVC 5-9.9%), or moderate/severe (LVC≥10%). Symptoms were assessed with a validated lymphedema instrument. Longitudinal logistic regression analyses were conducted to identify risk factors associated with moderate/severe lymphedema.

RESULTS

Among 205 breast cancer and 144 melanoma patients, the cumulative incidence of moderate/severe lymphedema at 18 months was 36.5% and 35.0%, respectively. However, in adjusted analyses, factors associated with moderate/severe lymphedema were breast cancer (OR 2.0, P = 0.03), body mass index ≥ 30 kg/m(2) (OR 1.6, P = 0.04), greater number of lymph nodes removed (OR 1.05, P < 0.01), and longer interval since surgery (OR 2.33 at 18 months, P < 0.01).

CONCLUSIONS

Lymphedema incidence increased over time in both cohorts. However, the adjusted risk of moderate/severe lymphedema was two-fold higher in breast cancer patients. These results may be attributed to surgical treatment of the primary tumor in the breast and more frequent use of radiation.

Label-free Detection of Lymph Node Metastases with US-guided Functional Photoacoustic Imaging

PURPOSE

To determine the ability of ultrasonography (US)-guided spectroscopic photoacoustic (sPA) imaging to depict changes in blood oxygen saturation (SO2) in metastatic lymph nodes of a mouse model of oral cancer.

MATERIALS AND METHODS

All studies were performed by following protocols approved by the institutional animal care and use committee at the University of Texas at Austin. Coregistered US and photoacoustic images were acquired spanning volumes containing a total of 31 lymph nodes in 17 female nu/nu mice. The mice were either healthy (three mice, five nodes) or bearing a primary tumor consisting of luciferase-labeled FaDu cells (14 mice, 26 nodes). Ten photoacoustic images acquired with optical wavelengths spanning from 680 to 860 nm were spectrally unmixed by using a linear least-squares method to obtain sPA images. After imaging, histologic analysis enabled confirmation of the presence of micrometastases. Generalized estimating equations were used to compare metastatic and normal lymph nodes, with a P value of .05 taken to indicate a significant difference. Sensitivity and specificity were determined with a receiver operator characteristic curve constructed from the background-subtracted SO2 values.

RESULTS

Metastatic lymph nodes (n = 7) exhibited a significantly (P = .018) lower spatially averaged background-subtracted SO2 (mean, 5.4% ± 3.5 [standard error]) when compared with lymph nodes without metastases (mean, 13.7% ± 1.3; n = 24). This effect was observed throughout the entire volume of the nodes rather than being limited to the metastatic foci. The change in SO2, which was inversely related to the size of the metastasis, was detectable in metastases as small as 2.6 × 10(-3) mm(3).

CONCLUSION

The results show that US-guided sPA imaging is capable of depicting changes in SO2 in lymph nodes that were correlated with metastatic invasion.

Incidence and time path of lymphedema in sentinel node negative breast cancer patients: a systematic review

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.

Self-perceived, but not objective lymphoedema is associated with decreased long-term health-related quality of life after breast cancer surgery

BACKGROUND

The primary aim was to compare long-term health-related quality of life (HRQoL) in patients undergoing sentinel lymph node biopsy (SLNB) alone versus axillary lymph node dissection (ALND), with or without axillary metastases. Secondary aims were to a) investigate agreement between objectively measured and self-reported lymphoedema and b) compare, with respect to HRQoL, women with objective arm lymphoedema without subjective ratings and those with no objective but subjective ratings of arm lymphoedema.

METHODS

The three study groups were defined by axillary surgery: 1) SLNB alone (N = 140), 2) ALND in patients without axillary metastases (N = 125) and 3) ALND in patients with axillary metastases (N = 155). Preoperatively, one and three years postoperatively arm volume was measured and questionnaires regarding self-perceived symptoms of arm lymphoedema and HRQoL were completed (The Swedish Short Form-36 Health Survey, SF-36).

RESULTS

Out of the original 516 who had axillary surgery, 420 (81%) completed the study. There were no statistically significant differences in HRQoL between the three study groups. No statistically significant agreement was found between self-perceived and objectively measured arm lymphoedema. Women without self-perceived arm lymphoedema, regardless of objective arm lymphoedema or not, scored higher on all eight SF-36 domains than those who reported self-perceived arm lymphoedema.

CONCLUSION

Women reporting self-perceived arm lymphoedema, regardless of objective lymphoedema or not, have a decreased long-term health-related quality of life. This indicates that more attention should be given to the subjective reports of symptom in order to better help these women.

Association of the number of sentinel lymph nodes harvested with survival in breast cancer

AIMS

In patients with breast cancer, the association between the number of sentinel lymph node (SLN) removed and survival is poorly known. Our objective was to evaluate this association on disease-specific survival (DSS).

METHODS

Data of 144 517 patients with invasive T1-3M0 breast carcinoma and initial treatment with SLN biopsy were extracted from the SEER database. Univariate and multivariate analyses were performed.

RESULTS

The number of SLNs harvested and the completion of axillary lymph node dissection (ALND) were not associated with DSS improvement for patients without metastatic nodes. After adjustment, patients with three SLNs had a better DSS than did other groups (HR of 0.73 CI 95% [0.60-0.88], p = 0.001). This result was mainly driven by the group of patients with one metastatic LN. When patients had two or more metastatic LNs, there was no difference in DSS according to the number of SLNs or to completion of ALND.

CONCLUSIONS

The number of SLN harvested was associated with DSS. According to DSS, the optimal number of SLNs harvested was three in this large series, thereby calling into question the understaging or undertreatment of SLN biopsy in which only one or two SLNs are harvested but also the therapeutic effect of completion ALND.

VEGF-C improves regeneration and lymphatic reconnection of transplanted autologous lymph node fragments: An animal model for secondary lymphedema treatment

Secondary lymphedema occurs after for example breast cancer surgery and radiation in 20–50% of the patients. Due to the poor outcomes of surgical treatments in the past, the therapy often remains symptomatic. However, avascular transplantation of autologous lymph node fragments (LN-Tx) combined with postoperative injections of vascular endothelial growth factor-C (VEGF-C) emerges as a potential surgical therapy. In this study, adult rats underwent LN-Tx to investigate the following parameters of VEGF-C application: time point, location and dosage. Furthermore, the influences of VEGF-C on lymphatic reconnection and transplant regeneration were analyzed. The reconnection was investigated using intradermally injected blue dye and the regeneration was evaluated histologically using hematoxylin-eosin (H&E) staining and immunohistochemistry. The higher dosage enhanced the reconnection rates significantly and showed a statistical tendency of improving regeneration. An application on early postoperative days and the injection into the medial thigh improved the reconnection significantly. However, these variables did not affect the regeneration statistically. This study confirms that LN-Tx combined with lymphatic growth factor VEGF-C is a possible approach in the therapy of secondary lymphedema and shows the important role of VEGF-C application parameters.

Sentinel lymph node biopsy revisited: ultrasound-guided photoacoustic detection of micrometastases using molecularly targeted plasmonic nanosensors

Metastases rather than primary tumors are responsible for killing most patients with cancer. Cancer cells often invade regional lymph nodes (LN) before colonizing other parts of the body. However, due to the low sensitivity and specificity of current imaging methods to detect localized nodal spread, an invasive surgical procedure--sentinel LN biopsy--is generally used to identify metastatic cancer cells. Here, we introduce a new approach for more sensitive in vivo detection of LN micrometastases, based on the use of ultrasound-guided spectroscopic photoacoustic (sPA) imaging of molecularly activated plasmonic nanosensors (MAPS). Using a metastatic murine model of oral squamous cell carcinoma, we showed that MAPS targeted to the epidermal growth factor receptor shifted their optical absorption spectrum to the red-near-infrared region after specific interactions with nodal metastatic cells, enabling their noninvasive detection by sPA. Notably, LN metastases as small as 50 μm were detected at centimeter-depth range with high sensitivity and specificity. Large sPA signals appeared in metastatic LN within 30 minutes of MAPS injection, in support of the clinical utility of this method. Our findings offer a rapid and effective tool to noninvasively identify micrometastases as an alternate to sentinal node biopsy analysis.

Arm lymphoedema after axillary surgery in women with invasive breast cancer

BACKGROUND

The primary aim was to compare arm lymphoedema after sentinel lymph node biopsy (SLNB) alone versus axillary lymph node dissection (ALND) in women with node-negative and node-positive breast cancer. The secondary aim was to examine the potential association between self-reported and objectively measured arm lymphoedema.

METHODS

Women who had surgery during 1999-2004 for invasive breast cancer in four centres in Sweden were included. The study groups were defined by the axillary procedure performed and the presence of axillary metastases: SLNB alone, ALND without axillary metastases, and ALND with axillary metastases. Before surgery, and 1, 2 and 3 years after operation, arm volume was measured and a questionnaire regarding symptoms of arm lymphoedema was completed. A mixed model was used to determine the adjusted mean difference in arm volume between the study groups, and generalized estimating equations were employed to determine differences in self-reported arm lymphoedema.

RESULTS

One hundred and forty women had SLNB alone, 125 had node-negative ALND and 155 node-positive ALND. Women who underwent SLNB had no increase in postoperative arm volume over time, whereas both ALND groups showed a significant increase. The risk of self-reported arm lymphoedema 1, 2 and 3 years after surgery was significantly lower in the SLNB group compared with that in both ALND groups. Three years after surgery there was a significant association between increased arm volume and self-reported symptoms of arm lymphoedema.

CONCLUSION

SLNB is associated with a minimal risk of increased arm volume and few symptoms of arm lymphoedema, significantly less than after ALND, regardless of lymph node status.

Silica-coated gold nanoplates as stable photoacoustic contrast agents for sentinel lymph node imaging

A biopsy of the first lymph node to which a tumor drains-the sentinel lymph node (SLN)-is commonly performed to identify micrometastases. Image guidance of the SLN biopsy procedure has the potential to improve its accuracy and decrease its morbidity. We have developed a new stable contrast agent for photoacoustic image-guided SLN biopsy: silica-coated gold nanoplates (Si-AuNPs). The Si-AuNPs exhibit high photothermal stability when exposed to pulsed and continuous wave laser irradiation. This makes them well suited for in vivo photoacoustic imaging. Furthermore, Si-AuNPs are shown to have low cytotoxicity. We tested the Si-AuNPs for SLN mapping in a mouse model where they exhibited a strong, sustained photoacoustic signal. Real-time ultrasound and photoacoustic imaging revealed that the Si-AuNPs quickly drain to the SLN, gradually spreading throughout a large portion of the node.

Risk factors of lymph edema in breast cancer patients

Background. Lymphedema secondary to breast cancer treatment is a common and serious problem for disease survivors. The objective of the current study was to identify the risk factors of secondary lymphedema after breast carcinoma treatment. Materials & Methods. The breast cancer patients who were followed up in three centers in Tehran and Mashhad in 2010 were recruited in the study. The circumference measurement was used for defining lymphedema. Results. Among 410 breast cancer patients, 123 cases (30%) developed lymphedema. Variables such as low educational level, body mass index (BMI), higher stage of disease, number of involved lymph nodes, comorbid diseases, trauma, infection, and the time after surgery showed significant correlation with the development of lymphedema. In logistic regression analysis, increase of 1 kg/m² in BMI (OR = 1.09; 95%  CI 1.05–1.15), each number increase in lymph node involvement (OR = 1.15; 95%  CI 1.08–1.21) and the increase of every 1 month after surgery (OR = 1.01; 95%  CI 1.01–1.02) significantly increased the risk of lymphedema. Conclusion. The results of this study demonstrated that preserving a fitted BMI, emphasis on self-care, and educating preventive activities may have important roles in decreasing the lymphedema incidence and improving the patients' quality of life.

Incidence of unilateral arm lymphoedema after breast cancer: a systematic review and meta-analysis

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.

Leg swelling after inguinal sentinel lymph node biopsy and primary melanoma excision with a safety margin

BACKGROUND

Risk-factors for leg swelling following primary melanoma excision and inguinal sentinel lymphadenectomy (SLNE) have not been sufficiently investigated.

PATIENTS AND METHODS

We prospectively studied three parameters in 105 subjects: 1) subjectively perceived swelling, 2) clinically diagnosed swelling and 3) photo-optical measurement of volume differences between both legs.

RESULTS

Perceived swelling, clinically diagnosed swelling, and manifest edema occurred in 31%, 15%, and 7% of patients respectively. Following inguinal SLNE, there was a mean volume increase of 1.5% in the operated leg. Both the lower leg and the thigh increased in volume. Obesity, primary melanoma location on the lower leg, and inguinal seromas were identified as significant risk factors for postoperative swelling. Wider excision margins around a primary melanoma on the thigh were also associated with a significant increase in volume. Age, sex, the number of sentinel lymph nodes, the drainage fluid volume, and the time since SLNE were non-significant.

CONCLUSIONS

Both inguinal SLNE and primary melanoma excision may contribute to minimal fluid accumulation in the leg. More than two-thirds of patients did not have any swelling. Obesity, location of the primary melanoma at a distal site on the leg, a wide safety margin, and seromas are associated with postoperative leg swelling.

The impact of immediate breast reconstruction on post-mastectomy lymphedema in patients undergoing modified radical mastectomy

The aim of this study was to assess the impact of immediate breast reconstruction (IBR) with autologous tissue on the development of post-mastectomy lymphedema in patients undergoing modified radical mastectomy (MRM). A retrospective chart review was performed for early-stage breast cancer patients who underwent MRM between January 2001 and December 2009. Patients were categorized into two groups based on whether or not they underwent IBR. The incidence of lymphedema was assessed and compared. A total of 712 patients underwent MRM, which included 117 patients undergoing IRB. There were no significant differences between two groups except for a lower body mass index in the reconstruction group. Comparing the incidence of lymphedema using multivariate logistic regression analysis, the reconstruction group had a significantly lower incidence of lymphedema (p-value = 0.023). Breast cancer patients who underwent MRM with IBR had a significantly lower incidence of lymphedema than those in the non-reconstruction group.