An audit of the incidence of arm lymphoedema after prophylactic level I/II axillary dissection without division of the pectoralis minor muscle

Localised Objective Characterisation Assessment of Lymphoedema (LOCAL): Using High-Frequency Ultrasound, Bioelectrical Impedance Spectroscopy and Volume to Evaluate Superficial Tissue Composition

Lymphoedema tissue is characterised by excess free fluid and structural changes to the extracellular matrix (ECM) in the form of fibrotic and fatty deposition. These tissue characteristics are integral to the assessment of lymphoedema progression; however, clinicians and researchers often focus on changes in the free fluid, volume and function of lymphatic vasculature to inform practice. Subsequently, little is known about the effect of clinical interventions on lymphoedema tissue composition. This article presents a novel approach to classify lymphoedema tissue. The Localised Objective Characterisation Assessment of Lymphoedema (LOCAL) classification combines diagnostic and clinically meaningful objective assessment thresholds to infer lymphoedema pathophysiological changes in tissue layers. The LOCAL classification method was verified using data from fifteen women with unilateral breast cancer-related lymphoedema who were evaluated at three sites on each arm using high-frequency ultrasound (HFUS), bio-electrical impedance spectroscopy (BIS) and volume measurements. Participants exhibited an uneven distribution of volume between the proximal and distal segments of the arm (p = 0.023), with multiple tissue compositional categories observed across sites on the same limb (p < 0.001). The LOCAL method demonstrated utility in categorising a diverse range of lymphoedema tissue layer changes beyond what can be ascertained from whole-limb measures.

What Should We Focus on When Managing Breast Cancer-Related Lymphedema to Improve Quality of Life?

Background: Breast cancer-related lymphedema (BCRL) is correlated with poor quality of life (QOL). The effects of the management of lymphedema on QOL remain controversial. We analyzed the changes in QOL and identified factors associated with its improvement to improve the care of patients with BCRL. Methods and Results: A total of 194 patients with BCRL were recruited, and their medical records were reviewed regarding type of surgery, chemotherapy, and radiation. Patients completed the European Organization for Research and Treatment of Cancer Quality of Life Questionnaires, and the volume and circumference of lymphedema were measured. Significant improvements in physical, emotional, cognitive, social, and role functioning, and future perspective were observed after BCRL management. However, the change in the size of lymphedema was not correlated with the change in QOL parameters. Conclusion: The management of BCRL has a beneficial effect on QOL. However, changes in the size of lymphedema did not reflect changes in QOL. Therefore, a comprehensive approach for the management of BCRL beyond reducing the size of lymphedema is recommended to improve QOL.

Lymphatic channel sheet of polydimethylsiloxane for preventing secondary lymphedema in the rat upper limb model

Secondary lymphedema is a severe complication of cancer treatment, but there is no effective curative method yet. Lymph node dissection and radiation therapy for cancer treatment may lead to secondary lymphedema, which is a chronic disease induced by malfunction of lymphatic flow. The lymphatic channel sheet (LCS) is an artificial micro-fluidic structure that was fabricated with polydimethylsiloxane to maintain lymphatic flow and induce lymphangiogenesis. The structure has two-dimensional multichannels that increase the probability of lymphangiogenesis and allow for relatively easy application. We verified the efficacy of the lymphatic channel sheet through macroscopic and microscopic observation in small animal models, which underwent brachial lymph node dissection and irradiation. The lymphatic channel sheet enabled the successful transport of lymphatic fluid from the distal to the proximal area in place of the removed brachial lymph nodes. It prevented swelling and abnormal lymphatic drainage during the follow-up period. Lymphangiogenesis was also identified inside the channel by histological analysis after 8 weeks. According to these experimental results, we attest to the roles of the lymphatic channel sheet as a lymphatic pathway and scaffold in the rat upper limb model of secondary lymphedema. The lymphatic channel sheet maintained lymphatic flow after lymph node dissection and irradiation in an environment where lymph flow is cut off. It also relieved symptoms of secondary lymphedema by providing a lymph-friendly space and inducing lymphangiogenesis.

The Psychosocial Effects of Cancer-Related Lymphedema

Life-long lymphedema is a common complication of cancer therapy. In this Canadian study, we adopted a phenomenological methodology to explore the experience of patients with cancer-related lymphedema, and their spouses. We conducted audio taped semistructured interviews with 11 patients and eight spouses, who were recruited through a university hospital-based lymphedema clinic and through local lymphedema therapists. We developed an analytical framework from the data themselves, and tentative hypotheses and thematic categories that represented shared case features. Participants expressed frustration because of lack of financial support from government and insurance companies, inadequate knowledge and perceived lack of interest on the part of physicians, and lack of awareness in society in general. This study suggests further investigation of the funding of lymphedema treatments, and of the effect of lymphedema on work, intimacy, and leisure activities. Our research findings will inform educational initiatives and cancer rehabilitation programs.

Evaluation of Stiffness in Postmastectomy Lymphedema Using Acoustic Radiation Force Impulse Imaging: A Prospective Randomized Controlled Study for Identifying the Optimal Pneumatic Compression Pressure to Reduce Stiffness

PURPOSE

We aimed to assess the improvement in stiffness in patients with postmastectomy lymphedema (PMLE) after intermittent pneumatic compression (IPC) using acoustic radiation force impulse (ARFI) imaging and evaluate the effects of different IPC pressures.

METHODS

We randomly assigned 45 patients with PMLE (stage II) to three groups based on the IPC pressure: 25, 35, and 45 mmHg. Patients received a single session of IPC for 30 minutes. We recorded the subcutaneous tissue thickness of the proximal upper limbs using ultrasonography and circumference of the upper limbs and stiffness using ARFI before and immediately after IPC.

RESULTS

Arm circumference and subcutaneous tissue thickness were significantly decreased after IPC in all groups. The shear wave velocity (SWV) decreased after IPC in all groups, but significantly decreased only in the 35 mmHg group. The subcutaneous tissue thickness and SWV in the 35 mmHg group were significantly decreased compared to the other groups.

CONCLUSION

IPC can reduce stiffness and subcutaneous tissue thickness of the proximal upper arm in patients with PMLE. A pressure of 35 mmHg yields the largest improvement of stiffness; higher compression pressure did not yield any additional improvement.

Chemotherapy port related lymphedema after axillary lymph node dissection

The Mascagni lymphatic pathway comprises superficial channels along the clavicle that drain upper extremity lymph. A 65 year-old woman with recurrent left breast cancer presented with a non-functioning chemotherapy port in the right deltopectoral groove. She had undergone right mastectomy with axillary lymph node dissection (ALND). After port removal and wound closure she developed right upper extremity lymphedema. Patients who have undergone ALND may depend solely on this pathway for upper extremity lymphatic drainage.

LEVEL OF EVIDENCE

level V.

The prevalence of lymphoedema in women who attended an information and exercise class to reduce the risk of breast cancer-related upper limb lymphoedema

Breast cancer-related upper limb lymphoedema (BCRL) affects approximately 20 % of women undergoing axillary intervention. Women who attended a “reducing your risk of lymphoedema” class, including exercise instruction, anecdotally reported positive BCRL outcomes. The aim of this study was to examine BCRL outcomes and perceived benefit for attendees at a “reducing your risk of lymphoedema” class between 2000 and 2005. A cross-sectional study was conducted in two parts: (1) self-report questionnaire regarding lymphoedema status and benefit received from class and exercise programme; (2) clinical evaluation and objective measurement to confirm BCRL. 46 women completed questionnaires; 40 continued to clinical evaluation and objective measurement. BCRL prevalence defined as ≥10 % excess limb volume was only 5 %, although clinician judgement identified 23 % with arm lymphoedema and 8 % with lymphoedema limited to the hand. Clinician judgement correlated highly with patient self-report (Kappa = 0.833, p = 0.000). All women found the class beneficial, reporting increased confidence to return to normal life and a wide range of activities/exercise. We conclude that prevalence of BCRL should be determined by both clinical judgement and objective measurement to avoid underestimation. The benefit of group education with a lymphoedema expert and of exercise instruction should be further explored, and the potential for exercise to reduce BCRL prevalence should be examined.

A constitutional predisposition to breast cancer-related lymphoedema and effect of axillary lymph node surgery on forearm muscle lymph flow

AIM

The aims of this prospective study were (a) to examine the relationship between pre-operative muscle lymph flow and the predisposition to BCRL in women treated by axillary nodal surgery for breast cancer; and (b) to test the 'stopcock' hypothesis that axillary lymph node surgery impairs forearm lymph flow in the short term.

METHODS

(99m)Tc-nanocoll was injected intramuscularly into both forearms of women undergoing surgery for breast cancer. Lymphatic clearance rate constant, k, representing lymph flow per unit interstitial fluid volume, was measured as the fractional disappearance rate of radioactivity from the depot site by gamma camera imaging. Axillary lymph node activity was calculated as percentage injected activity. BCRL was assessed by clinical examination and upper limb perometry.

RESULTS

Of 38 pre-operative women, 33 attended at 8 ± 6 weeks post-operatively and 31 at 58 ± 9 weeks post-operatively. Seven patients (18%) developed BCRL. Prior to surgery the BCRL-destined patients had a higher mean k (0.0962 ± 0.034%/min) than non-BCRL patients (0.0830 ± 0.019%/min) (p = 0.10, unpaired t test). Post-operative k values were not significantly different from pre-operative, in either the ipsilateral (operated) or contralateral limb. Also, post-operative k values did not differ significantly between both upper limbs. Furthermore, there was no significant difference between pre- and post-operative axillary activity.

CONCLUSION

Patients who develop BCRL have high lymph flow pre-surgery, which may predispose them to lymphatic overload and failure. Axillary lymph node surgery has no early, measurable effect on forearm muscle lymph flow despite surgical disruption of routes of lymph drainage.

Contrast-enhanced magnetic resonance lymphography in the assessment of lower limb lymphoedema

Chronic lower limb lymphoedema is a debilitating condition that may occur as a primary disorder or secondary to other conditions. Satisfactory visualization of the lymphatic vessels to aid diagnosis and surgical planning has been problematic. Historically, direct lymphography was used to visualize lymphatic vessels, although the significant surgical risks involved led to this being largely abandoned as a technique. Technetium-99m lymphoscintigraphy has been the mainstay of diagnosis for over two decades, but is hampered by inherently poor temporal and spatial resolution and limited anatomical detail. Contrast-enhanced magnetic resonance lymphography (MRL) is a relatively new technique that shows early promise in the evaluation of chronic lymphoedema. This article provides the procedural technique for lower limb MRL at both 1.5 and 3 T, discusses pathophysiology and classifications of lymphoedema, provides an overview of relevant lower limb lymphatic anatomy using MRL imaging, compares the various techniques used in the diagnosis of lower limb lymphoedema, shows common pathological MRL imaging findings, and describes alternative uses of MRL. Utilization of this technique will allow more accurate diagnosis and classification of patients suffering from lymphoedema.

Impact of body mass index and weight fluctuation on lymphedema risk in patients treated for breast cancer

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.

Running away from side effects: physical exercise as a complementary intervention for breast cancer patients

The number of breast cancer survivors increases every year, thanks to the development of new treatments and screening techniques. However, patients present with numerous side effects that may affect their quality of life. Exercise has been demonstrated to reduce some of these side effects, but in spite of this, few breast cancer patients know and follow the exercise recommendations needed to remain healthy. In this review, we describe the different breast cancer treatments and the related side effects and implications of exercise in relation to these. We propose that exercise could be an integrative complementary intervention to improve physiological, physical and psychological factors that affect survival and quality of life of these patients. For that reason, the main objective of this review is to provide a general overview of exercise benefits in breast cancer patients and recommendations of how to design exercise interventions in patients with different side effects.

Frequency of Early-Stage Lymphedema and Risk Factors in Postoperative Patients with Breast Cancer

OBJECTIVE

Lymphedema is a chronic major complication that is seen frequently post-operatively and has negative effects on quality of life. In our study, determining the early-stage postoperative lymphedema frequency and specifying the risk factors in its development has been aimed.

MATERIALS AND METHODS

One hundred one cases that were operated on for breast cancer were evaluated regarding the 12-month control of their clinical specifications, histopathological specifications, and specifications related with the surgical intervention retrospectively. The data related to the parameters envisioned as risk factors were evaluated.

RESULTS

Lymphedema development was found in 7 (6.9%) out of 101 cases constituting the study group. No significant difference (p>0.05) in terms of lymphedema development was determined among age, body mass index (BMI), chemotherapy (CT), postoperative seroma or infection, mastectomy with the dominant arm, and breast-conserving surgery (BCS), which were evaluated as risk factors. There was a significance (p<0.05) between the other risk factors, which were axillary dissection (AD), number of positive lymph nodes (LN), radiotherapy (RT), the tumor size (T), and lymphedema existence. In every case in which lymphedema was determined, it was seen that there was axillary LN involvement and 15≤LN were ablated in the dissection (p<0.05).

CONCLUSION

It is seen that AD, RT applied to the breast cancer patients, and T are important risk factors in early-stage lymphedema development. No early-stage lymphedema development was determined in any of the patients to whom sentinel lymph node dissection (SLND) was applied.

Defining a threshold for intervention in breast cancer-related lymphedema: what level of arm volume increase predicts progression?

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.

Clinical effectiveness of complex decongestive physiotherapy for malignant lymphedema: a pilot study

OBJECTIVE

To evaluate the effect of complex decongestive physiotherapy (CDPT) on malignant lymphedema patients.

METHODS

Patients (n=22) with malignant lymphedema of the upper or the lower limb were assigned to this study. CDPT without manual lymphatic drainage (MLD) was used five times per week for two weeks. The main outcome measurements included measurement of the circumference of the limb (proximal, distal, and total) to assess volume changes. We also employed the visual analog scale (VAS) to evaluate pain, and the short form-36 version 2 questionnaire (SF-36) to assess quality of life (QOL). All items were assessed pre and post-treatment for each patient.

RESULTS

There was a statistically significant difference in the volume change of the upper limbs (3.7%, p=0.001) and the lower limbs (10.9%, p=0.001). A 1.5 point reduction on the ten-point VAS was noted after CDPT. The scores on the physical and the mental components of the SF-36 showed statistical improvement after treatment (p=0.006, p=0.001, respectively).

CONCLUSION

These results suggest that all components of the CDPT program except MLD are helpful in treating malignant lymphedema in terms of pain reduction and reduction of the volume of the affected upper or lower limb. This treatment regimen also has positive effects on QOL.

Comparison of breast cancer-related lymphedema (upper limb swelling) prevalence estimated using objective and subjective criteria and relationship with quality of life

This study aimed to investigate lymphedema prevalence using three different measurement/diagnostic criterion combinations and explore the relationship between lymphedema and quality of life for each, to provide evaluation of rehabilitation. Cross-sectional data from 617 women attending review appointments after completing surgery, chemotherapy, and radiotherapy included the Morbidity Screening Tool (MST; criterion: yes to lymphedema); Lymphedema and Breast Cancer Questionnaire (LBCQ; criterion: yes to heaviness and/or swelling); percentage limb volume difference (perometer: %LVD; criterion: 10%+ difference); and the Functional Assessment of Cancer Therapy breast cancer-specific quality of life tool (FACT B+4). Perometry measurements were conducted in a clinic room. Between 341 and 577 participants provided sufficient data for each analysis, with mean age varying from 60 to 62 (SD 9.95-10.03) and median months after treatment from 49 to 51. Lymphedema prevalence varied from 26.2% for perometry %LVD to 20.5% for the MST and 23.9% for the LBCQ; differences were not significant. Limits of agreement analysis between %LVD and the subjective measures showed little consistency, while moderate consistency resulted between the subjective measures. Quality of life differed significantly for women with and without lymphedema only when subjective measurements were used. Results suggest that subjective and objective tools investigate different aspects of lymphedema.

Clinical outcomes of extracorporeal shock wave therapy in patients with secondary lymphedema: a pilot study

Objective

To investigate the clinical effect of extracorporeal shock wave therapy (ESWT) in patients with secondary lymphedema after breast cancer treatment.

Methods

In a prospective clinical trial, ESWT was performed consecutively 4 times over two weeks in 7 patients who were diagnosed with stage 3 secondary lymphedema after breast cancer treatment. Each patient was treated with four sessions of ESWT (0.056-0.068 mJ/mm², 2,000 impulses). The parameters were the circumference of the arm, thickness of the skin and volume of the arm. We measured these parameters with baseline values before ESWT and repeated the evaluation after each ESWT treatment. Subjective data on skin thickness, edema and sensory impairment were obtained using a visual analogue scale (VAS).

Results

The mean volume of the affected arm after four consecutive ESWT was significantly reduced from 2,332 to 2,144 mL (p<0.05). The circumference and thickness of the skin fold of the affected arm were significantly decreased after the fourth ESWT (p<0.05). The three VAS scores were significantly improved after the fourth ESWT. Almost all patients were satisfied with this treatment and felt softer texture in their affected arm after treatment.

Conclusion

ESWT is an effective modality in the treatment of stage 3 lymphedema after breast cancer treatment. ESWT reduced the circumference and the thickness of arms with lymphedema and satisfied almost all patients with lymphedema. Therefore, this treatment provides clinically favorable outcome to patients with breast cancer-related lymphedema.

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.

Lifestyle risk factors associated with arm swelling among women with breast cancer

BACKGROUND

Breast cancer-related lymphedema (BCRL) is a feared complication for breast cancer patients who have undergone axillary surgery. Although clinical risk factors for BCRL are defined, data are sparse regarding common exposures that might induce incident arm swelling. The goal of this study was to quantify the association between common exposures thought to be potential risk factors and the occurrence of incident arm swelling among breast cancer survivors with or at risk for BCRL.

METHODS

This is a prospective subanalysis of the Physical Activity and Lymphedema (PAL) trial, a randomized controlled trial of 295 breast cancer survivors. Participants reported their exposure to 30 different potential risk factors at 3 month intervals for 1 year. Incident arm swelling was defined as a ≥5% increase in interlimb water volume difference between two consecutive time points.

RESULTS

Twenty-seven participants (9%) experienced incident arm swelling and 268 patients (91%) did not. Sauna use was the only exposure that was significantly predictive of incident arm swelling (p = 0.05). Nonwhite and nonblack participants had a significantly increased risk for experiencing incident arm swelling (p = 0.005 for both comparisons).

CONCLUSIONS

In our patient cohort, many common exposures that have been reported to be risk factors did not prove to have a significant predictive relationship for incident arm swelling. This study supports the recommendation that breast cancer patients who have had axillary surgery should avoid sauna use. The results do not confirm the need for other restrictions that may interfere with the quality of life in women with breast cancer.

Systematic review of breast cancer related lymphoedema: making a balanced decision to perform an axillary clearance

AIM

Breast cancer-related lymphoedema (BCRL) is a disabling complication developing after breast cancer treatment in a proportion of patients. Its impact on quality of life becomes more substantial as survival after breast cancer diagnosis increases. The incidence of BCRL following breast cancer treatment varies due to a lack of -uniform definition and measurement criteria. This review aims to determine the prevalence of BCRL following axillary lymph node dissection (ALND) as a benchmark to be used in a risk-benefit medical decision whether to proceed with ALND or not. The risk of leaving unresected non-sentinel metastatic lymph nodes with a presumed inherent risk of local recurrence will be balanced against the risk of BCRL following a potentially unnecessary ALND.

METHODS

Pubmed and Embase databases were searched for all publications on BCRL in order to estimate its -incidence and to decide on the most appropriate measurement method to use in clinical practice.

RESULTS

51 articles were identified on BCRL incidence and measurement technique. Most studies measured BCRL based on differences in arm circumference (n = 18) or by self-reported symptoms (n = 18). The weighted average of BCRL incidence following ALND measured by self-report and circumference method was 28% and 16%, respectively.

CONCLUSION

The importance of ALND and irradiation as part of the treatment of operable breast carcinoma is well established, but its morbidity is less well documented. We argue self-report as the most appropriate method to -establish a diagnosis of BCRL. Therefore a 28% risk of finding non-sentinel lymph node metastases in a completion ALND will be regarded as the cut-off in a medical decision to proceed with ALND.

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

BACKGROUND

Sentinel lymph node biopsy (SLNB) is associated with reduced morbidity, although lymphedema remains a significant complication. Previously, we found no association between number of excised lymph nodes (LNs) and measured lymphedema in SLNB patients. In this analysis, we examined the relationship between number of LNs excised during SLNB and patient-perceived lymphedema.

METHODS

A total of 600 women who underwent SLNB for breast cancer were prospectively studied. Measured lymphedema was evaluated by circumferential bilateral upper-extremity measurements taken preoperatively and 3-8 years postoperatively. Patient-perceived lymphedema was evaluated by interview at follow-up. The relationship between lymphedema, total LNs excised, and clinicopathologic variables was assessed with Fisher's exact test, Wilcoxon rank-sum test, kappa statistic, and McNemar's test.

RESULTS

At a median of 5 years, 18 (3%) patients reported perceived lymphedema. More LNs were excised in patients with perceived lymphedema compared with those without (median, 5.5 vs. 3; p = 0.01). Only 6 of 18 women with perceived lymphedema had objectively measured lymphedema (kappa = 0.22). Patients with numbness more likely reported perceived lymphedema (p = 0.03) and had more LNs excised (p = 0.02). Women with surgery on the nondominant axilla were less likely to perceive arm swelling, regardless of the presence of measured lymphedema.

CONCLUSIONS

After SLNB alone, patient-perceived lymphedema is uncommon, but its prevalence increases with more LNs excised. There is poor agreement between patient perceptions and objective measures. Our data suggest that factors other than limb enlargement, such as sensory nerve injury resulting from retrieval of more LNs and laterality of surgery, may play a significant role in patient perception of lymphedema after SLNB.

Study of incidence of lymphedema in Indian patients undergoing axillary dissection for breast cancer

Lymphedema of the upper extremity, in addition to being unsightly, can be painful, can limit the arm movements, increases the risk of infection and is psychologically distressing, serving as a constant reminder of cancer. 1. To ascertain the incidence of lymphedema in a hospital based population (in patients undergoing axillary dissection for breast cancer. 2. To determine the clinico-epidemilogical factors associated with the occurrence of lymphedema in these patients. For all patients undergoing axillary dissection, arm measurements were taken in the pre-& post-operative period from at least 3 sites; one in the arm, forearm and wrist (points fixed in reference to fixed bony landmarks). Patients included in this study were followed up for at least 12 months. Circumference difference of more than 5% was taken as mild lymphedema; more than 10% as moderate lymphedema and more than 15% as severe lymphedema. Data was analyzed using SPSS 11.0 statistical software. Of the 231 patients in this study mean age was 51.2 years, majority were housewives (71.9%) and postmenopausal (58.5%). Modified radical mastectomy (MRM), was performed on 203 (87.9%) patients. 57.2% patients had positive lymph nodes. The mean number of positive nodes was 6.52. Majority of the patients received chemo and radio therapy. Overall incidence of lymphedema was 41.1%. The definition of 5-10% increase as mild lymphedema may be a bit severe as in most patients with this increase, lymphedema is not clinically apparent. The incidence of moderate and severe lymphedema in our series is only 7.4%. The incidence of clinically significant lymphedema (moderate to severe lymphedema & symptomatic mild lymphedema) was 16.8%. Only axillary irradiation and pathological nodal status (pN3) emerged as significant risk factors for lymphedema development on multivariate analysis. Lymphedema once established is difficult to treat. Combination of axillary dissection with radiation and more nodal positivity seems to predispose to lymphedema. Prevention by means of sentinel node biopsy in early cases, good surgical technique, arm care post surgery, exercises and massage therapy may help reducing the incidence and/or severity.

Effect of active resistive exercise on breast cancer-related lymphedema: a randomized controlled trial

OBJECTIVE

To investigate the differences between the effects of complex decongestive physiotherapy with and without active resistive exercise for the treatment of patients with breast cancer-related lymphedema (BCRL).

DESIGN

Randomized control-group study.

SETTING

An outpatient rehabilitation clinic.

PARTICIPANTS

Patients (N=40) with diagnosed BCRL.

INTERVENTIONS

Patients were randomly assigned to either the active resistive exercise group or the nonactive resistive exercise group. In the active resistive exercise group, after complex decongestive physiotherapy, active resistive exercise was performed for 15min/d, 5 days a week for 8 weeks. The nonactive resistive exercise group performed only complex decongestive physiotherapy.

MAIN OUTCOME MEASURES

The circumferences of the upper limbs (proximal, distal, and total) for the volume changes, and the Short Form-36 version 2 questionnaire for the quality of life (QOL) at pretreatment and 8 weeks posttreatment for each patient.

RESULTS

The volume of the proximal part of the arm was significantly more reduced in the active resistive exercise group than that of the nonactive resistive exercise group (P<.05). In the active resistive exercise group, there was significantly more improvement in physical health and general health, as compared with that of the nonactive resistive exercise group (P<.05).

CONCLUSIONS

For the treatment of patients with BCRL, active resistive exercise with complex decongestive physiotherapy did not cause additional swelling, and it significantly reduced proximal arm volume and helped improve QOL.

Lymphatic drainage in the muscle and subcutis of the arm after breast cancer treatment

Breast cancer-related lymphoedema of the arm (BCRL) results from impaired lymph drainage after axillary surgery. Little is known about lymphatic changes in the arm between surgery and oedema onset. We measured forearm muscle and subcutis lymph drainage in 36 women at 7 and 30 months after surgery by quantitative lymphoscintigraphy. None had BCRL initially but 19% had BCRL by 30 months. At 7 months muscle and subcutis drainage in both arms of BCRL-destined women exceeded that of non-BCRL women (P < 0.01). Muscle lymph drainage always exceeded subcutis drainage (P < 0.0001). Muscle lymph drainage in the ipsilateral arm was unimpaired relative to the contralateral arm. BCRL therefore developed in women with higher peripheral lymph flows. The major lymphatic load was generated by muscle; there was no pre-BCRL lymphatic impairment in the muscle of the ipsilateral arm. We propose that some women have a defined, constitutive predisposition to secondary lymphoedema. Specifically, women with higher filtration rates, and therefore higher lymph flows through the axilla that are closer to the maximum sustainable, are at greater risk of BCRL following axillary trauma, even following removal of 1-2 nodes.

Breast cancer treatment, BMI, post-op swelling/lymphoedema

BACKGROUND: Diagnosis of post-breast cancer lymphoedema is difficult because of inconsistent measurement approaches, measurement reliability and validity, and lymphoedema definition and criterion. AIMS: To examine lymphoedema occurrence using a body mass index (BMI)-adjusted limb volume change (LVC) as a potentially sensitive alternative criterion for assessment and diagnosis of lymphoedema. Secondary aims were to examine the risk of lymphoedema occurrence in relation to post-operative swelling and limb dominance and the cancer-affected side. METHODS: The volume calculated from circumferences of 193 breast cancer survivors was used to analyse lymphoedema assessment. A change ≥5% in affected-arm volume over percent change in BMI in comparison to pre-operative baseline was considered indicative of lymphoedema. RESULTS: For all participants, 63% met the 5% BMI-adjusted LVC criterion. Dominant limb and cancer-affected side were significantly related to lymphoedema occurrence only in those whose BMI ≥30 (p=0.02), while post-operative swelling significantly increased the lymphoedema risk irrespective of BMI (p=0.01). CONCLUSIONS: The proposed 5% BMI-adjusted LVC criterion provides a more sensitive estimation of post-breast cancer lymphoedema occurrence.

Lymphedema After Breast Cancer: Incidence, Risk Factors, and Effect on Upper Body Function

Purpose

Secondary lymphedema is associated with adverse physical and psychosocial consequences among women with breast cancer (BC). This article describes the prevalence and incidence of lymphedema between 6 and 18 months after BC treatment; personal, treatment, and behavioral correlates of lymphedema status; and the presence of other upper-body symptoms (UBS) and function (UBF).

Patients and Methods

A population-based sample of Australian women (n = 287) with recently diagnosed, invasive BC were evaluated on five occasions using bioimpedance spectroscopy. Lymphedema was diagnosed when the ratio of impedance values, comparing treated and untreated sides, was three standard deviations more than normative data. UBF was assessed using the validated Disability of the Arm, Shoulder, and Hand questionnaire.

Results

From 6 to 18 months after surgery, 33% (n = 62) of the sample were classified as having lymphedema; of these, 40% had long-term lymphedema. Although older age, more extensive surgery or axillary node dissection, and experiencing one or more treatment-related complication(s) or symptom(s) at baseline were associated with increased odds, lower socioeconomic status, having a partner, greater child care responsibilities, being treated on the dominant side, participation in regular activity, and having good UBF were associated with decreased odds of lymphedema. Not surprisingly, lymphedema leads to reduced UBF; however, BC survivors report high prevalences of other UBS (34% to 62%), irrespective of their lymphedema status.

Conclusion

Lymphedema is a public health issue deserving greater attention. More systematic surveillance for earlier detection and the potential benefits of physical activity to prevent lymphedema and mitigate symptoms warrant further clinical integration and research.

Lymphedema: a comprehensive review

BACKGROUND

Lymphedema is a chronic, debilitating condition that has traditionally been seen as refractory or incurable. Recent years have brought new advances in the study of lymphedema pathophysiology, as well as diagnostic and therapeutic tools that are changing this perspective.

OBJECTIVE

To provide a systematic approach to evaluating and managing patients with lymphedema.

METHODS

We performed MEDLINE searches of the English-language literature (1966 to March 2006) using the terms lymphedema, breast cancer-associated lymphedema, lymphatic complications, lymphatic imaging, decongestive therapy, and surgical treatment of lymphedema. Relevant bibliographies and International Society of Lymphology guidelines were also reviewed.

RESULTS

In the United States, the populations primarily affected by lymphedema are patients undergoing treatment of malignancy, particularly women treated for breast cancer. A thorough evaluation of patients presenting with extremity swelling should include identification of prior surgical or radiation therapy for malignancy, as well as documentation of other risk factors for lymphedema, such as prior trauma to or infection of the affected limb. Physical examination should focus on differentiating signs of lymphedema from other causes of systemic or localized swelling. Lymphatic dysfunction can be visualized through lymphoscintigraphy; the diagnosis of lymphedema can also be confirmed through other imaging modalities, including CT or MRI. The mainstay of therapy in diagnosed cases of lymphedema involves compression garment use, as well as intensive bandaging and lymphatic massage. For patients who are unresponsive to conservative therapy, several surgical options with varied proven efficacies have been used in appropriate candidates, including excisional approaches, microsurgical lymphatic anastomoses, and circumferential suction-assisted lipectomy, an approach that has shown promise for long-term relief of symptoms.

CONCLUSIONS

The diagnosis of lymphedema requires careful attention to patient risk factors and specific findings on physical examination. Noninvasive diagnostic tools and lymphatic imaging can be helpful to confirm the diagnosis of lymphedema or to address a challenging clinical presentation. Initial treatment with decongestive lymphatic therapy can provide significant improvement in patient symptoms and volume reduction of edematous extremities. Selected patients who are unresponsive to conservative therapy can achieve similar outcomes with surgical intervention, most promisingly suction-assisted lipectomy.

Lymph node status and breast cancer-related lymphedema

OBJECTIVE

This study examines the association between nodal positivity and risk of developing breast cancer-related lymphedema (BCRL) in patients who underwent axillary lymph node dissection (ALND).

SUMMARY BACKGROUND DATA

The pathophysiology of BCRL is poorly understood. It has been assumed that one of the factors predisposing to the development of BCRL is nodal positivity, although retrospective series have produced contradictory findings. As these studies have included treatment regimens known to cause BCRL, such as axillary radiotherapy, any relationship between nodal positivity and the development of BCRL remains speculative.

METHODS

A total of 212 patients who had undergone ALND for invasive breast cancer had arm volume measurements preoperatively, and at intervals postoperatively. No patient received axillary radiotherapy. Arm volumes were obtained by measuring serial arm circumferences every 4 cm up the arm and then calculated by using the formula for the volume of a truncated cone. Robust regression techniques were used to analyze the effects of node positivity, age, preoperative body mass index, and wound infection on arm volume excess.

RESULTS

In all, 64 of 212 (30%) patients were node positive. Contrary to previous assumptions, positive node status was significantly inversely associated with arm volume after adjusting for tumor size, time since operation, and allowing for correlated observations within subjects. Furthermore, the number of positive nodes also correlated inversely with arm volume.

CONCLUSION

These results are counterintuitive to the conventional understanding of the pathophysiology of BCRL. A possible explanation is that patients who develop disease in axillary lymph nodes and subsequently undergo ALND have more time and ability to develop lymphatic collaterals, which may provide adequate lymphatic drainage following surgery, thereby reducing the risk of developing BCRL.

Surgical complications associated with sentinel lymph node dissection (SLND) plus axillary lymph node dissection compared with SLND alone in the American College of Surgeons Oncology Group Trial Z0011

PURPOSE

The American College of Surgeons Oncology Group trial Z0011 was a prospective, randomized, multicenter trial comparing overall survival between patients with positive sentinel lymph nodes (SLNs) who did and did not undergo axillary lymph node dissection (ALND). The current study compares complications associated with SLN dissection (SLND) plus ALND, versus SLND alone.

PATIENTS AND METHODS

From May 1999 to December 2004, 891 patients were randomly assigned to SLND + ALND (n = 445) or SLND alone (n = 446). Information on wound infection, axillary seroma, paresthesia, brachial plexus injury (BPI), and lymphedema was available for 821 patients.

RESULTS

Adverse surgical effects were reported in 70% (278 of 399) of patients after SLND + ALND and 25% (103 of 411) after SLND alone (P <or= .001). Patients in the SLND + ALND group had more wound infections (P <or= .0016), seromas (P <or= .0001), and paresthesias (P <or= .0001) than those in the SLND-alone group. At 1 year, lymphedema was reported subjectively by 13% (37 of 288) of patients after SLND + ALND and 2% (six of 268) after SLND alone (P <or= .0001). The difference between the two groups' lymphedema, assessed by arm measurements at 30 days (P = .36), 6 months (P = .22), and 1 year (P = .078), although close to the cutoff for significance at 1 year, was not significant. BPIs occurred in less than 1% of patients.

CONCLUSION

In trial Z0011, the use of SLND + ALND resulted in more wound infections, axillary seromas, and paresthesias than SLND alone. Lymphedema was more common after SLND + ALND but was significantly different only by subjective report. The use of SLND alone resulted in fewer complications.

Lymphedema following axillary lymph node dissection for breast cancer

Lymphedema is a relatively common, potentially serious and unpleased complication after axillary lymph node dissection (ALND) for breast cancer. It may be associated with functional, esthetic, and psychological problems, thereby affecting the quality-of-life (QOL) of breast cancer survivors. Objective measurements (preferentially by measuring arm volumes or arm circumferences at predetermined sites) are required to identify lymphedema, but also subjective assessment can help to determine the clinical significance of any volume/circumference differences. Lymphedema per se predisposes to the development of other secondary complications, such as infections of the upper limb, psychological sequelae, development of malignant tumors, alterations of the QOL, etc. The risk of lymphedema is associated with the extent of ALND and the addition of axillary radiation therapy. Treatment involves the application of therapeutic measures of the so-called decongestive lymphatic therapy. Prevention is of key importance to avoid lymphedema formation. The application of the sentinel lymph node biopsy in the management of breast cancer has been associated with a reduced incidence of lymphedema formation.

Risks and benefits of needle use in patients after axillary node surgery

Lymphoedema may be triggered by any type of injection. This is not just an issue for the cured breast cancer patient but for any patient who has undergone under-arm (axillary) lymph node removal to any degree for any type of cancer. Standard advice given to patients following axillary node removal is to avoid any injection or blood pressure measurement on the ipsilateral arm. The evidence base in this area is severely lacking. Patients have reported frustration that nurses are not informed of contraindications in carrying out such procedures on patients at risk of developing swelling. This article discusses the current evidence available on the subject of non-accidental skin puncture (NASP) relating to the patient at risk of lymphoedema and provides guidelines for any professionals conducting such procedures for patients with a history of cancer. The results from a small audit of the guidelines are cited and they reveal that out of 14 patients who underwent NASP procedures in the at risk arm, no patients reported swelling to that limb within a month of these procedures.

Axillary staging in women with small invasive breast tumours

AIMS

To identify a group of women with small breast cancers of favourable histological grade for whom observation alone may be an acceptable approach for management of the axilla.

METHODS

In a retrospective analysis the incidence of nodal metastases was examined in a group of 355 consecutive patients over 55 years of age who underwent mastectomy or breast conserving surgery. All patients had either grade I (<20 mm) or grade II (<15 mm) oestrogen receptor positive tumours without lymphovascular invasion (LVI). In a related study on 173 clinically node negative patients, the rate of axillary recurrence was assessed in patients with small (<10 mm), non-high grade (I and II), ER-positive invasive ductal carcinomas without LVI. Axillary surgery was either omitted (135 patients) or delayed (38 patients) at the time of wide local excision or mastectomy.

RESULTS

The overall incidence of positive nodes in this good prognostic group of patients was 13% (95% confidence interval 9.5-16.5). When the analysis was confined to grade I (< or =20 mm) and grade II (< or =10 mm) the overall incidence of nodal metastases was 10%. Rates of axillary recurrence at a median follow up of 49 months were only 1% when axillary surgery was omitted according to patient choice/departmental policy with no cases of uncontrolled axillary recurrence.

CONCLUSION

The risk:benefit ratio for detection of node positive cases in a selected group of older patients does not justify any form of axillary procedure at the time of primary surgery.

Breast cancer-related lymphedema

Every year in the United States, breast cancer is diagnosed in more than 200,000 women. Because of the prevalence of breast cancer, treatment-related sequelae are of Importance to many survivors of the disease. One such sequela is upper extremity lymphedema, which occurs when fluid accumulates in the Interstitial space and causes enlargement and usually a feeling of heaviness in the limb. Axillary surgery contributes considerably to the incidence of lymphedema, with the incidence and severity of swelling related to the number of lymph nodes removed. Lymphedema after standard axillary lymph node dissection can occur in up to approximately 50% of patients. However, the risk of lymphedema is decreased substantially with newer sentinel lymph node sampling procedures. Adjuvant radiotherapy to the breast or lymph nodes increases the risk of lymphedema, which has been reported in 9% to 40% of these patients. Management of lymphedema requires a multidisciplinary approach to minimize the effect on the patient's quality of life. This review presents an overview of the pathophysiology, diagnosis, prevention, and treatment of breast cancer-related lymphedema.

Regional distribution of epifascial swelling and epifascial lymph drainage rate constants in breast cancer-related lymphedema

BACKGROUND

The view that breast cancer-related lymphedema (BCRL) is a simple, direct mechanical result of axillary lymphatic obstruction ('stopcock' mechanism) appears incomplete, because parts of the swollen limb (e.g., hand) can remain nonswollen. The lymph drainage rate constant (k) falls in the swollen forearm but not in the spared hand, indicating regional differences in lymphatic function. Here the generality of the hypothesis that regional epifascial lymphatic failure underlies regional swelling was tested. To do so, the regional distribution of epifascial swelling along the forearm was compared with that of epifascial (subcutis) k.

METHODS AND RESULTS

Epifascial k (local lymph flow per unit distribution volume) was measured by quantitative lymphoscintigraphy of subcutaneous radiolabeled human immunoglobulin IgG in regions of maximal and minimal % swelling in the ipsilateral swollen forearm, and at matching sites in the contralateral nonswollen arm, in 11 women with BCRL. Swelling was maximal distally in 5 patients and proximally in 6. Proximal k, -0.085 +/- 0.025% min(-1) (mean +/- SD), was 27% bigger than distal k, -0.067 +/- 0.021% min(-1), irrespective of swelling (p = 0.02, two-way repeated measures ANOVA). k fell by 11% from -0.080 +/- 0.028% min(-1) in the nonswollen arm to -0.072 +/- 0.021% min(-1) in the swollen arm (p = 0.17, t test). Local epifascial k was not significantly lower, however, at sites of maximal swelling than minimal swelling, and k correlated positively with arm circumference.

CONCLUSIONS

A systematic difference in lymph drainage along the axis of the forearm was demonstrated for the first time. Local differences in epifascial k did not, however, explain the regionality of swelling, in keeping with previous evidence that epifascial k does not correlate with differences in swelling between arms, whereas subfascial k does. The results lead to the rejection of the hypothesis that epifascial (cf. subfascial) lymph drainage rate constants govern epifascial swelling in human forearm.

Lymphoedema: estimating the size of the problem

Lymphoedema is a problem frequently encountered by professionals working in palliative care. This article reviews the evidence on the magnitude of the problem of lymphoedema in the general population and provides evidence on specific high risk groups within it. Prevalence is a good indicator of the burden of disease for chronic problems such as lymphoedema, as it indicates the numbers of patients who require care. Incidence is indicative of changes in the causes of lymphoedema and the success of any prevention programmes. Both are important means of assessing the current level of need and the potential for the changing needs in managing this condition. Problems exist in all studies in relation to precise definitions of lymphoedema, inconsistent measures to assess differential diagnosis and poorly defined populations. While there is some evidence of high rates in relation to breast cancer therapy, the total burden of lymphoedema in the general population is largely unknown.

Axillary vein abnormalities contribute to development of lymphoedema after surgery for breast cancer

Background

The aetiology of breast cancer-related lymphoedema (BCRL) is poorly understood and multifactorial. Previous work has suggested that acquired abnormalities of the axillary vein may contribute to arm swelling. This prospective study evaluated venous changes in patients with a new diagnosis of breast cancer who had surgery that included axillary lymph node clearance.

Methods

Patients underwent arm volume measurement and Doppler ultrasonographic assessment of the axillary vein before, and at 3 and 12 months after surgery.

Results

A complete data set was available for 70 patients. BCRL was observed in 16 per cent at 3 months and 11 per cent at 12 months. Significant alterations to venous flow patterns were observed in those with BCRL. Vein wall movement was significantly reduced after surgery for the group as a whole, but did not correlate with arm swelling. Venous stenosis with impaired flow was also observed in the absence of BCRL.

Conclusion

Axillary clearance can cause altered flow within the axillary vein, which is associated with an increased risk of developing lymphoedema.