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Chen Z, Ghavimi SAA, Wu M, McNamara J, Barreiro O, Maridas D, Kratchmarov R, Siegel A, Djeddi S, Gutierrez-Arcelus M, Brennan PJ, Padera TP, von Andrian U, Mehrara B, Greene AK, Kahn CR, Orgill DP, Sinha I, Rosen V, Agarwal S. PPARγ agonist treatment reduces fibroadipose tissue in secondary lymphedema by exhausting fibroadipogenic PDGFRα+ mesenchymal cells. JCI Insight 2023; 8:e165324. [PMID: 38131378 PMCID: PMC10807713 DOI: 10.1172/jci.insight.165324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 11/10/2023] [Indexed: 12/23/2023] Open
Abstract
Secondary lymphedema occurs in up to 20% of patients after lymphadenectomy performed for the surgical management of tumors involving the breast, prostate, uterus, and skin. Patients develop progressive edema of the affected extremity due to retention of protein-rich lymphatic fluid. Despite compression therapy, patients progress to chronic lymphedema in which noncompressible fibrosis and adipose tissue are deposited within the extremity. The presence of fibrosis led to our hypothesis that rosiglitazone, a PPARγ agonist that inhibits fibrosis, would reduce fibrosis in a mouse model of secondary lymphedema after hind limb lymphadenectomy. In vivo, rosiglitazone reduced fibrosis in the hind limb after lymphadenectomy. Our findings verified that rosiglitazone reestablished the adipogenic features of TGF-β1-treated mesenchymal cells in vitro. Despite this, rosiglitazone led to a reduction in adipose tissue deposition. Single-cell RNA-Seq data obtained from human tissues and flow cytometric and histological evaluation of mouse tissues demonstrated increased presence of PDGFRα+ cells in lymphedema; human tissue analysis verified these cells have the capacity for adipogenic and fibrogenic differentiation. Upon treatment with rosiglitazone, we noted a reduction in the overall quantity of PDGFRα+ cells and LipidTOX+ cells. Our findings provide a framework for treating secondary lymphedema as a condition of fibrosis and adipose tissue deposition, both of which, paradoxically, can be prevented with a pro-adipogenic agent.
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Affiliation(s)
- Ziyu Chen
- Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Bone and Joint Surgery, Peking University Shenzhen Hospital, Shenzhen Peking University-The Hong Kong University of Science and Technology Medical Center, Shenzhen, Guangdong, China
| | - Soheila Ali Akbari Ghavimi
- Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Mengfan Wu
- Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - David Maridas
- Harvard School of Dental Medicine, Boston, Massachusetts, USA
| | - Radomir Kratchmarov
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ashley Siegel
- Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Sarah Djeddi
- Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Maria Gutierrez-Arcelus
- Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Patrick J. Brennan
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Timothy P. Padera
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | | | - Babak Mehrara
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Arin K. Greene
- Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - C. Ronald Kahn
- Joslin Diabetes Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Dennis P. Orgill
- Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Indranil Sinha
- Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Vicki Rosen
- Harvard School of Dental Medicine, Boston, Massachusetts, USA
| | - Shailesh Agarwal
- Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Li H, Li WB, Sun ZX, Yu J, Lv PY, Li CX, Liang X, Yu Y, Zhao ZB. Analysis of the Risk Factors of Breast Cancer-Related Lymphedema and Construction and Evaluation of a Prediction Model. Lymphat Res Biol 2023; 21:565-573. [PMID: 37768813 DOI: 10.1089/lrb.2022.0058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023] Open
Abstract
Objective: The occurrence of breast cancer-related lymphedema (BCRL) in postoperative breast cancer survivors is described and the independent risk factors of BCRL are analyzed. A BCRL nomogram prediction model is constructed, and its effectiveness is evaluated to screen out high-risk patients with BCRL. Methods: A univariate analysis was carried out to determine the risk factors possibly related to BCRL, and a logistic regression analysis was utilized to determine the independent risk factors related to BCRL. A BCRL nomogram prediction model was built, and a nomogram was drawn by R software v4.1.0. The area under the curve (AUC) of the receiver operating characteristic (ROC) and the Hosmer-Lemeshow test were used to evaluate the efficacy of the constructed model to assess its clinical application value. Results: The risk factors independently associated with BCRL were body mass index (BMI), handedness on the operation side, no BCRL-related rehabilitation plan, axillary lymph node dissection (ALND), taxane-based chemotherapy, and radiotherapy (all p < 0.05). The BCRL nomogram prediction model was built on this basis, and the results of the efficacy evaluation showed a good fit: AUC = 0.952 (95% confidence interval: 0.930-0.973) for the ROC and χ2 = 6.963, p = 0.540 for the Hosmer-Lemeshow test. Conclusions: The risk factors for BCRL included higher BMI, handedness on the operation side, no BCRL-related rehabilitation plan, ALND, taxane-based chemotherapy, and radiotherapy. In addition, the BCRL nomogram prediction model accurately calculated the risk of possible BCRL among breast cancer survivors and effectively screened for high-risk patients with BCRL. Therefore, this prediction model can provide a basis for rehabilitation physicians and therapists to formulate early and individualized prevention and treatment programs.
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Affiliation(s)
- Hui Li
- Department of Rehabilitation, Hebei Medical University, Heibei, China
| | - Wei-Bo Li
- Department of Gastrointestinal Surgery, The Second Hospital of Hebei Medical University, Heibei, China
| | - Zeng-Xin Sun
- Department of Rehabilitation, Heibei General Hospital, Heibei, China
| | - Jing Yu
- Department of Rehabilitation, Hebei Medical University, Heibei, China
| | - Pei-Yuan Lv
- Department of Internal Medicine-Neurology, Hebei Provincial Key Laboratory of Cerebral Networks and Cognitive Disorders, Heibei, China
| | - Chun-Xiao Li
- Department of Rehabilitation, Hebei Medical University, Heibei, China
| | - Xiao Liang
- Department of Rehabilitation, Hebei Medical University, Heibei, China
| | - Yin Yu
- Department of Rehabilitation, Hebei Medical University, Heibei, China
- Department of Rehabilitation, Heibei General Hospital, Heibei, China
| | - Zhen-Biao Zhao
- Department of Rehabilitation, Hebei Medical University, Heibei, China
- Department of Rehabilitation, Heibei General Hospital, Heibei, China
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Aguilera-Eguía RA, Gutiérrez-Arias R, Zaror C, Seron P. Effectiveness of physical exercise programmes in reducing complications associated with secondary lymphoedema to breast cancer: a protocol for an overview of systematic reviews. BMJ Open 2023; 13:e071630. [PMID: 37429694 DOI: 10.1136/bmjopen-2023-071630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/12/2023] Open
Abstract
INTRODUCTION Breast cancer-related lymphoedema (BCRL) is one of the most underestimated and debilitating complications associated with the treatment that women with breast cancer receive. Several systematic reviews (SRs) of different physical exercise programmes have been published, presenting disperse and contradictory clinical results. Therefore, there is a need for access to the best available and summarised evidence to capture and evaluate all the physical exercise programmes that focus on reducing BCRL. OBJECTIVE To evaluate the effectiveness of different physical exercise programmes in reducing the volume of lymphoedema, pain intensity and improving quality of life. METHOD AND ANALYSIS The protocol of this overview is reported following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols, and its methodology is based on Cochrane Handbook for Systematic Reviews of Interventions. Only those SRs involving physical exercise by patients with BCRL will be included, whether on its own or combined with other exercises or other physical therapy interventions.The outcomes of interest to be considered will be lymphoedema volume, quality of life, pain intensity, grip strength, range of motion, upper limb function and any adverse event. The MEDLINE/PubMed, Lilacs, Cochrane Library, PEDro and Embase databases will be searched for reports published from database inception to April 2023.Two researchers will perform study selection, data extraction and risk of bias assessment independently. Any discrepancy will be resolved by consensus, or ultimately, by a third-party reviewer. We will use Grading of Recommendations Assessment, Development and Evaluation System to assess the overall quality of the body of evidence. ETHICS AND DISSEMINATION The results of this overview will be published in peer-reviewed scholarly journals and the scientific dissemination will take place in national or international conferences. This study does not require approval from an ethics committee, as it does not directly collect information from patients. PROSPERO REGISTRATION NUMBER CRD42022334433.
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Affiliation(s)
- Raúl Alberto Aguilera-Eguía
- Departamento de Salud Pública, Facultad de Medicina, Universidad Católica de la Santísima Concepción, Concepcion, Chile
- Department of Paediatrics, Obstetrics and Gynaecology and Preventive Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ruvistay Gutiérrez-Arias
- Departamento de Apoyo en Rehabilitación Cardiopulmonar Integral, Instituto Nacional del Tórax, Santiago, Chile
- Exercise and Rehabilitation Sciences Institute, Faculty of Rehabilitation Sciences, Universidad Andres Bello, Santiago 7591538, Santiago, Chile
| | - Carlos Zaror
- Pediatric Dentist and Orthodontic, Universidad de La Frontera, Temuco, Chile
| | - Pamela Seron
- CIGES, Universidad de La Frontera, Temuco, Chile
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Chen ST, Lai HW, Wu WP, Chen ST, Liao CY, Wu HK, Chen DR, Mok CW. The impact of body mass index (BMI) on MRI diagnostic performance and surgical management for axillary lymph node in breast cancer. World J Surg Oncol 2022; 20:45. [PMID: 35193599 PMCID: PMC8864912 DOI: 10.1186/s12957-022-02520-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 02/11/2022] [Indexed: 11/22/2022] Open
Abstract
Background We hypothesized that different BMI might have different impact on pre-operative MRI axillary lymph node (ALN) prediction accuracy and thereby subsequent surgical lymph node management. The aim of this study is to evaluate the effect of BMI on presentation, surgical treatment, and MRI performance characteristics of breast cancer with the main focus on ALN metastasis evaluation. Methods The medical records of patients with primary invasive breast cancer who had pre-operative breast MRI and underwent surgical resection were retrospectively reviewed. They were categorized into 3 groups in this study: underweight (BMI < 18.5), normal (BMI of 18.5 to 24), and overweight (BMI > 24). Patients’ characteristics, surgical management, and MRI performance for axillary evaluation between the 3 groups were compared. Results A total of 2084 invasive breast cancer patients with a mean age of 53.4 ± 11.2 years were included. Overweight women had a higher rate of breast conserving surgery (56.7% vs. 54.5% and 52.1%) and initial axillary lymph node dissection (15.9% vs. 12.2% and 8.5%) if compared to normal and underweight women. Although the post-operative ALN positive rates were similar between the 3 groups, overweight women were significantly found to have more axillary metastasis on MRI compared with normal and underweight women (50.2% vs 37.7% and 18.3%). There was lower accuracy in terms of MRI prediction in overweight women (65.1%) than in normal and underweight women (67.8% and 76.1%). Conclusion Our findings suggest that BMI may influence the diagnostic performance on MRI on ALN involvement and the surgical management of the axilla in overweight to obese women with breast cancer.
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Affiliation(s)
- Shu-Tian Chen
- Department of Diagnostic Radiology, Chang Gung Memorial Hospital-Chiayi Branch, Chiayi, Taiwan.,Chang Gung University College of Medicine, Taoyuan City, Taiwan.,Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Hung-Wen Lai
- Chang Gung University College of Medicine, Taoyuan City, Taiwan. .,Endoscopy & Oncoplastic Breast Surgery Center, Changhua Christian Hospital, Changhua, Taiwan. .,Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan. .,Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan. .,Minimal Invasive Surgery Research Center, Changhua Christian Hospital, Changhua, Taiwan. .,Kaohsiung Medical University, Kaohsiung, Taiwan. .,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan. .,School of Medicine, Chung Shan Medical University, Taichung, Taiwan. .,Division of General Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
| | - Wen-Pei Wu
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Radiology, Changhua Christian Hospital, Changhua, Taiwan
| | - Shou-Tung Chen
- Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan.,Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Chiung-Ying Liao
- Department of Radiology, Changhua Christian Hospital, Changhua, Taiwan
| | - Hwa-Koon Wu
- Department of Radiology, Changhua Christian Hospital, Changhua, Taiwan
| | - Dar-Ren Chen
- Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan.,Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Chi Wei Mok
- Division of Breast Surgery, Department of Surgery, Changi General Hospital, Singapore, Singapore.,Singhealth Duke-NUS Breast Centre, Singapore, Singapore
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Martínez-Jaimez P, Armora Verdú M, Forero CG, Álvarez Salazar S, Fuster Linares P, Monforte-Royo C, Masia J. Breast cancer-related lymphoedema: Risk factors and prediction model. J Adv Nurs 2021; 78:765-775. [PMID: 34363640 DOI: 10.1111/jan.15005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/08/2021] [Accepted: 07/24/2021] [Indexed: 12/30/2022]
Abstract
AIMS To identify the risk factors for lymphoedema following axillary lymph node dissection (ALND) in a European sample and to propose a lymphoedema prediction model for this population. DESIGN Predictive retrospective cohort study comparing women who developed lymphoedema in 2 years of undergoing ALND with those who did not developed lymphoedema. METHODS We reviewed the clinical records of 504 women who, between January 2008 and May 2018, underwent surgery for breast cancer that involved ALND. Logistic regression was used to identify significant risk factors for lymphoedema. The prediction accuracy of the model was assessed by calculating the area under the receiver operating characteristic curve. RESULTS Of the 504 women whose records were analysed, 156 developed lymphoedema. Significant predictors identified in the regression model were level of lymph node dissection, lymph node status, post-operative complications, body mass index (BMI) and number of lymph nodes extracted. The prediction model showed good sensitivity (80%) in the study population. CONCLUSIONS The factor contributing most to the risk of lymphoedema was the level of lymph node dissection, and the only patient-related factor in the prediction model was BMI. The model offers good predictive capacity in this population and it is a simple tool that breast care units could use to assess the risk of lymphoedema following ALND. Nurses with specialist knowledge of lymphoedema have a key role to play in ensuring that women receive holistic and individualized care. IMPACT What problem did the study address? Secondary lymphoedema is one of the main complications in the treatment of breast cancer. What were the main findings? The prediction model included five factors associated with the risk of lymphoedema following ALND. The strongest predictor was the level of lymph node dissection, and the only patient-related factor was BMI. Where and on whom will the research have an impact? The prediction model offers breast care units a tool for assessing the risk of lymphoedema in women undergoing surgery involving ALND. The results highlight the importance of weight reduction as a preventive measure and support a more conservative surgical approach.
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Affiliation(s)
- Patricia Martínez-Jaimez
- Breast Reconstruction and Lymphoedema Surgery Unit, Clínica Planas, Barcelona, Spain.,Nursing Department. Faculty of Medicine and Health Science, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Miriam Armora Verdú
- Nursing Department, Hospital de la Santa Creu i Sant Pau, Universitat Autonòma de Barcelona, Barcelona, Spain
| | - Carlos G Forero
- Department of Medicine. Faculty of Medicine and Health Sciences, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Samantha Álvarez Salazar
- Department of Medicine. Faculty of Medicine and Health Sciences, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Pilar Fuster Linares
- Nursing Department. Faculty of Medicine and Health Science, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Cristina Monforte-Royo
- Nursing Department. Faculty of Medicine and Health Science, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Jaume Masia
- Breast Reconstruction and Lymphoedema Surgery Unit, Clínica Planas, Barcelona, Spain.,Nursing Department, Hospital de la Santa Creu i Sant Pau, Universitat Autonòma de Barcelona, Barcelona, Spain.,Department of Plastic Surgery, Hospital del Mar, Barcelona, Spain
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Assessment of Potential Risk Factors and Skin Ultrasound Presentation Associated with Breast Cancer-Related Lymphedema in Long-Term Breast Cancer Survivors. Diagnostics (Basel) 2021; 11:diagnostics11081303. [PMID: 34441238 PMCID: PMC8393908 DOI: 10.3390/diagnostics11081303] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 06/10/2021] [Accepted: 06/21/2021] [Indexed: 12/31/2022] Open
Abstract
Breast cancer has been reported to have the highest survival rate among various cancers. However, breast cancer survivors face several challenges following breast cancer treatment including breast cancer-related lymphedema (BCRL), sexual dysfunction, and psychological distress. This study aimed to investigate the potential risk factors of BCRL in long term breast cancer survivors. A total of 160 female breast cancer subjects were recruited on a voluntary basis and arm lymphedema was assessed through self-reporting of diagnosis, arm circumference measurement, and ultrasound examination. A total of 33/160 or 20.5% of the women developed BCRL with significantly higher scores for upper extremity disability (37.14 ± 18.90 vs. 20.08 ± 15.29, p < 0.001) and a lower score for quality of life (103.91 ± 21.80 vs. 115.49 ± 16.80, p = 0.009) as compared to non-lymphedema cases. Univariate analysis revealed that multiple surgeries (OR = 5.70, 95% CI: 1.21–26.8, p < 0.001), axillary lymph nodes excision (>10) (OR = 2.83, 95% CI: 0.94–8.11, p = 0.047), being overweight (≥25 kg/m2) (OR = 2.57, 95% CI: 1.04 – 6.38, p = 0.036), received fewer post-surgery rehabilitation treatment (OR = 2.37, 95% CI: 1.05–5.39, p = 0.036) and hypertension (OR = 2.38, 95% CI: 1.01–5.62, p = 0.043) were associated with an increased risk of BCRL. Meanwhile, multivariate analysis showed that multiple surgeries remained significant and elevated the likelihood of BCRL (OR = 5.83, 95% CI: 1.14–29.78, p = 0.034). Arm swelling was more prominent in the forearm area demonstrated by the highest difference of arm circumference measurement when compared to the upper arm (2.07 ± 2.48 vs. 1.34 ± 1.91 cm, p < 0.001). The total of skinfold thickness of the affected forearm was also significantly higher than the unaffected arms (p < 0.05) as evidenced by the ultrasound examination. The continuous search for risk factors in specific populations may facilitate the development of a standardized method to reduce the occurrence of BCRL and provide better management for breast cancer patients.
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