Risk Factors for Lymphedema in Breast Cancer Survivors Following Axillary Lymph Node Dissection

Predesigned chimeric deep inferior epigastric perforator and inguinal lymph node flap for combined breast and lymphedema reconstruction: A comprehensive algorithmic approach

The combined use of a deep inferior epigastric perforator (DIEP) flap coupled with vascularized inguinal lymph nodes (VILNs) for simultaneous breast and lymphedema reconstruction has already been well established, and promising results have been reported. However, a standardized approach for the planning and shaping of this combined flap is still lacking. We aimed to propose a comprehensive algorithmic approach for delayed unilateral breast and lymphedema reconstruction using a predesigned abdominal flap associated with inguinal lymph node transfer. We present in detail the preoperative measurements and surgical technique of the chimeric flap, which combines a predesigned DIEP template and a preselected inguinal lymph node flap, based on the preoperative computed tomography angiography and SPEC-CT findings, respectively; four different flap types are described according to the location of the pedicles of the two flap components. Our results of a series of 34 consecutive female patients with unilateral mastectomy and arm lymphedema, who underwent this combined predesigned reconstructive procedure, are retrospectively analyzed and reported. We recorded a high survival rate of the chimeric flaps in our series, with only one case of partial ischemic loss of a DIEP skin island. In the majority of our patients, the pedicles of the combined flaps were located in opposite positions. After a mean 35-month follow-up, we recorded a 47% mean volume difference reduction of the lymphedematous compared to the unaffected arm; no donor-site lymphedema was documented. Self-evaluation questionnaires showed high patient satisfaction rates regarding breast reconstruction. This algorithmic approach provides standardized guidance for accurate design and transfer of the DIEP-VILN chimeric flap while achieving highly satisfactory outcomes for both breast and lymphedema reconstruction.

Time trend of breast cancer-related lymphedema according to body mass index

PURPOSE

To clarify how body mass index (BMI) affects the development and temporal trend of breast cancer-related lymphedema (BCRL).

METHODS

This is a prospective study in which patients with operable breast cancer were registered in a single institute between November 2009 and July 2010. The incidence of lymphedema at 1, 3, and 5 years after surgery was assessed according to BMI, and the trend of newly developed BCRL was examined. Obesity was defined as BMI ≥25 in accordance with the Japan Society for the Study of Obesity.

RESULTS

A total of 368 patients were included in this study. The multivariate analysis of the whole population showed that high BMI, axillary dissection, and radiotherapy remained as risk factors for BCRL. Patients with high BMI showed a significantly higher incidence of new lymphedema than those with low BMI at 1 year (p < 00.001) regardless of axillary procedures (39.1 % vs 16.3 % for axillary dissection; 15.6 % vs 1.5 % for sentinel lymph node biopsy) but not at 3 and 5 years. Once BCRL developed, patients with high BMI showed slow recovery and 50.0 % of the patients retained edema at 5 years while patients with low BMI showed rapid recovery and 26.7 % retained after 3 years (p = 0.04).

CONCLUSION

The preoperative BMI affected the incidence and temporal trend of BCRL regardless of axillary procedures or radiotherapy. Patients with high BMI should be given appropriate information about BCRL before surgery with careful follow-up for BCRL after treatment.

Lymphedema after regional nodal irradiation for breast cancer: a retrospective cohort study

Purpose

We aimed to analyze the occurrence of lymphedema as a side effect in patients who underwent regional nodal irradiation (RNI) following surgery for breast cancer.

Methods

This retrospective study was conducted on patients with breast cancer who underwent surgery from July 2014 to October 2020 at Inje University Busan Paik Hospital. The analysis included 113 cT1-3N1-3M0 breast cancer patients who underwent RNI as part of radiotherapy (RT). Mostly, surgeries were performed using breast-conserving surgery (n = 99, 87.6%), except for 14 patients with modified radical mastectomy. The total RT dose for RNI was 45-60 Gy, and the fraction size was 1.8-2.0 Gy. Most patients underwent chemotherapy (n = 98, 86.7%), including taxanes (n = 92, 81.4%).

Results

The median follow-up was 61.1 months (range, 5.0-110.5 months). Lymphedema occurred in 54 patients (47.8%) after surgery. Twenty of them (17.7%) developed a new onset of lymphedema after RT, while 34 (30.1%) detected lymphedema before the completion of RT. Over the follow-up, 16 patients (14.2%) experienced recurrence. High radiation dose (>50.4 Gy) for RNI (P = 0.003) and taxane use (P = 0.038) were related to lymphedema occurrence after RT. Moreover, lymphedema occurrence after RT was also related to recurrence after surgical resection (P = 0.026). Breast-conserving surgery was related to early-onset lymphedema before the completion of RT (P = 0.047). Furthermore, the degree of lymph node dissection (≤4) was related to the overall occurrence of lymphedema (P = 0.045).

Conclusion

Considering a reduction in RNI dose may be beneficial in mitigating the incidence of lymphedema after RT in patients with breast cancer.

Biofeedback-Based Proprioceptive Training to Improve Functional Prerequisites of Dragon Boating in Breast Cancer Survivors

Breast cancer (BC)-related sequelae drastically impact the psychophysical functioning and quality of life of affected women. Adapted physical activity (APA) has proved to effectively counteract these impairments in a non-medicalized framework. In particular, dragon boats are able to promote body functionality, social interaction, and quality of life in BC survivors, but the literature on specific motor gestures is scarce and practice is still based more on a re-educative perspective than a performative one. In this context, the present longitudinal study investigated the benefits of an adapted biofeedback-based sensorimotor training intervention on upper body functionality in a team of dragon ladies. The 8-week intervention was conceived as integrated dry workout sessions led by an APA kinesiologist and applied a novel sensorized proprioceptive device, such as a Libra board. Post-protocol evaluation revealed a significant improvement in bilateral upper limb mobility, core endurance, and trunk stability along with a distress decrease and quality of life enhancement through validated assessment tools. Our findings suggest that integrating biofeedback-based workout sessions can effectively promote upper body functionality in BC survivors practicing dragon boating. Furthermore, our innovative approach could help spread methodological hints able to boost exercise adherence in this target population, thus counteracting cancer recurrence while promoting overall well-being.

A multivariable model of ultrasound and clinicopathological features for predicting axillary nodal burden of breast cancer: potential to prevent unnecessary axillary lymph node dissection

BACKGROUND

To develop a clinical model for predicting high axillary nodal burden in patients with early breast cancer by integrating ultrasound (US) and clinicopathological features.

METHODS AND MATERIALS

Patients with breast cancer who underwent preoperative US examination and breast surgery at the Affiliated Hospital of Nantong University (centre 1, n = 250) and at the Affiliated Hospital of Jiangsu University (centre 2, n = 97) between January 2012 and December 2016 and between January 2020 and March 2022, respectively, were deemed eligible for this study (n = 347). According to the number of lymph node (LN) metastasis based on pathology, patients were divided into two groups: limited nodal burden (0-2 metastatic LNs) and heavy nodal burden (≥ 3 metastatic LNs). In addition, US features combined with clinicopathological variables were compared between these two groups. Univariate and multivariate logistic regression analysis were conducted to identify the most valuable variables for predicting ≥ 3 LNs in breast cancer. A nomogram was then developed based on these independent factors.

RESULTS

Univariate logistic regression analysis revealed that the cortical thickness (p < 0.001), longitudinal to transverse ratio (p = 0.001), absence of hilum (p < 0.001), T stage (p = 0.002) and Ki-67 (p = 0.039) were significantly associated with heavy nodal burden. In the multivariate logistic regression analysis, cortical thickness (p = 0.001), absence of hilum (p = 0.042) and T stage (p = 0.012) were considered independent predictors of high-burden node. The area under curve (AUC) of the nomogram was 0.749.

CONCLUSION

Our model based on US variables and clinicopathological characteristics demonstrates that can help select patients with ≥ 3 LNs, which can in turn be helpful to predict high axillary nodal burden in early breast cancer patients and prevent unnecessary axillary lymph node dissection.

Risk factors of unilateral breast cancer-related lymphedema: an updated systematic review and meta-analysis of 84 cohort studies

PURPOSE

To review and update the incidence and risk factors for breast cancer-related lymphedema based on cohort studies.

METHODS

The study was guided by the Joanna Briggs Institute methodology and the Cochrane handbook for systematic reviews. PubMed, EMBASE, CINAHL, Scopus, Web of Science, The Cochrane Library, CNKI, SinoMed, and Wan Fang Database were searched from inception to November 15, 2021. Cohort studies reported adjusted risk factors were selected. PRISMA guideline was followed. Study quality were evaluated using the Newcastle-Ottawa scale. Random-effects models were adopted. The robustness of pooled estimates was validated by meta-regression and subgroup analysis. Lymphedema incidence and adjusted risk factors in the multivariable analyses with hazard / odds ratios and 95% CIs were recorded.

RESULTS

Eighty-four cohort studies involving 58,358 breast cancer patients were included. The pooled incidence of lymphedema was 21.9% (95% CI, 19.8-24.0%). Fourteen factors were identified including ethnicity (black vs. white), higher body mass index, higher weight increase, hypertension, higher cancer stage (III vs. I-II), larger tumor size, mastectomy (vs. breast conservation surgery), axillary lymph nodes dissection, more lymph nodes dissected, higher level of lymph nodes dissection, chemotherapy, radiotherapy, surgery complications, and higher relative volume increase postoperatively. Additionally, breast reconstruction surgery, and adequate finance were found to play a protective role. However, other variables such as age, number of positive lymph nodes, and exercise were not correlated with risk of lymphedema.

CONCLUSION

Treatment-related factors still leading the development of breast cancer-related lymphedema. Other factors such as postoperative weight increase and finance status also play a part. Our findings suggest the need to shift the focus from treatment-related factors to modifiable psycho-social-behavioral factors.