Breast Lymphedema Research Articles

Surgical Treatment of Breast Lymphedema: A Distinct Pathology With Unique Challenges.

Supermicrosurgical advances such as lymphovenous bypass (LVB) have enabled effective physiologic treatment of lymphedema affecting the extremities. Reports of surgical treatment for breast lymphedema (BL) are sparse, consisting of case reports and almost exclusively LVB. We report our experience with BL, including a case of mastectomy and breast reconstruction with abdominal free flap and inguinal vascularized lymph node transfer (VLNT) for BL. We compare our series with the surgical literature to discern unique characteristics and treatment limitations inherent to this disease. A database was prospectively maintained from September 2020 to May 2023 including all patients diagnosed with BL who were referred to our institution. Breast lymphedema was diagnosed using clinical criteria, and relevant patient data were recorded. Patients interested in surgical management underwent indocyanine green lymphography to determine candidacy for LVB or other interventions. All patients, including those surgically managed, were treated with complex decongestive therapy. Nine patients with BL were included. Eight had undergone breast-conserving therapy for breast cancer with whole breast irradiation. One patient was treated for Hodgkin lymphoma with axillary lymphadenectomy and axillary radiation. Indocyanine green lymphography was performed in 6 patients, of which 4 patients had diffuse dermal backflow. Two patients had lymphatic targets suitable for LVB, including the patient without breast irradiation. Three patients were managed surgically. One patient without bypass targets underwent breast reduction with partial symptomatic relief, later followed by a mastectomy with abdominal free flap reconstruction and VLNT. Two patients with suitable bypass targets underwent LVB, with resolution of breast swelling and subjective symptoms. The diffuse lymphatic obliteration due to radiation field effect in BL results in a distinct pathophysiology compared with extremity lymphedema. Although published reports of surgical BL treatment almost exclusively describe LVB, other surgical options may be more frequently required. Ablative strategies such as mastectomy and regenerative techniques such as VLNT should be considered potential first-line treatment options for these patients.

1530: Ultrasound Assessment of Breast Lymphedema Severity in Relation to Radiation Therapy

1530: Ultrasound Assessment of Breast Lymphedema Severity in Relation to Radiation Therapy

Alternative Lymphatic Drainage Pathways in the Trunk Following Oncologic Therapy.

Anatomic and functional descriptions of trunk and breast lymphedema following breast cancer treatment are emerging as indicators of lymphatic dysfunction. Indocyanine green-lymphangiography has been instrumental in characterizing this dysfunction in the extremity and can be applied to other regions. Previous work has established a validated Pittsburgh Trunk Lymphedema Staging System to characterize such affected areas. This study aims to identify risk and protective factors for the development of truncal and upper extremity lymphedema using alternative lymphatic drainage, providing implications for medical and surgical treatment. Patients undergoing revisional breast surgery with suspicion of upper extremity lymphedema between 12/2014 and 3/2020 were offered lymphangiography. The breast and lateral/anterior trunks were visualized and blindly evaluated for axillary and inguinal lymphatic flow. A linear-weighted Cohen's kappa statistic was calculated comparing alternative drainage evaluation. Binomial regression was used to compute relative risks (RRs). Significance was assessed at alpha = 0.05. Eighty-six sides (46 patients) were included. Twelve sides underwent no treatment and were considered controls. Eighty-eight percent of the noncontrols had alternative lymphatic flow to the ipsilateral axillae (64%), ipsilateral groins (57%), contralateral axillae (20.3%), and contralateral groins (9.3%). Cohen's kappa for alternative drainage was 0.631 ± 0.043. Ipsilateral axillary and contralateral inguinal drainage were associated with reduced risk of developing truncal lymphedema [RR 0.78, confidence interval (CI) 0.63-0.97, P = 0.04; RR 0.32, CI 0.13-0.79, P = 0.01, respectively]. Radiation therapy increased risk of truncal and upper extremity lymphedema (RR 3.69, CI 0.96-14.15, P = 0.02; RR 1.92, CI 1.09-3.39, P = 0.03, respectively). Contralateral axillary drainage and axillary lymph node dissection were associated with increased risk of upper extremity lymphedema (RR 4.25, CI 1.09-16.61, P = 0.01; RR 2.83, CI 1.23-6.52, P = 0.01, respectively). Building upon previous work, this study shows risk and protective factors for the development of truncal and upper extremity lymphedema. Most prevalent alternative channels drain to the ipsilateral axilla and groin. Ipsilateral axillary and contralateral inguinal drainage were associated with reduced risk of truncal lymphedema. Patients with radiation, axillary dissection, and contralateral axillary drainage were associated with increased risk of upper extremity lymphedema. These findings have important clinical implications for postoperative manual lymphatic drainage and for determining eligibility for lymphovenous bypass surgery.

Breast lymphedema following breast-conserving treatment for breast cancer: current status and future directions.

To examine the current evidence on breast lymphedema (BL) diagnosis and treatment after breast-conserving surgery, identify gaps in the literature, and propose future research directions. A comprehensive literature review was conducted using Ovid, PubMed, and Cochrane, including studies published between 2000 and 2023. References were reviewed manually for eligible studies. Inclusion criteria were as follows: patients who underwent breast conserving treatment (surgery ± radiation) for breast cancer, goals of the paper included analyzing or reviewing BL measurement with ultrasound or tissue dielectric constant, or BL treatment. Twenty-seven manuscripts were included in the review. There is variation in incidence, time course, and risk factors for BL. Risk factors for BL included breast size, primary and axillary surgery extent, radiation, and chemotherapy but require further investigation. Diagnostic methods for BL currently rely on patient report and lack standardized criteria. Tissue dielectric constant (TDC) and ultrasound (US) emerged as promising ambulatory BL assessment tools; however, diagnostic thresholds and validation studies with ICG lymphography are needed to establish clinical utility. The evidence base for treatment of BL is weak, lacking high-quality studies. The natural history of BL is not well defined. TDC and US show promise as ambulatory assessment tools for BL; however, further validation with lymphatic imaging is required. BL treatment is not established in the literature. Longitudinal, prospective studies including pre-radiation measurements and validating with lymphatic imaging are required. These data will inform screening, diagnostic criteria, and evidence-based treatment parameters for patients with BL after breast-conserving surgery and radiation.

Incidence, Radiologic and Dosimetric Parameters Associated with Radiation Induced Breast Lymphedema

Radiation induced breast lymphedema (BL) is an underreported but common finding. This study aimed to report the incidence of clinical BL and investigate the radiologic and dosimetric parameters associated with higher risk of BL. This IRB approved study included women with breast cancer who underwent breast conservative surgery followed by adjuvant radiation therapy between 2019 and 2021 at our institution. We reviewed the eligible patients' charts for incidence of clinical BL resulting in symptoms and requiring physical therapy referral. Thickness of the skin at defined center and bottom points of the breast was measured for patient' baseline and follow up mammograms. Dosimetric parameters were imported from patients' radiation plans including mean, maximum doses, and volumes receiving 20, 30, 40, & 50 Gy (V20, V30, V40, & V50), of the whole breast (WB), breast_eval (BE), and breast skin (BS) (defined as the superficial 5 mm of the skin). A chi-square test was used to test the association between clinical BL and radiation treatment regimens and beam energies and the association of skin thicknesses between those who had clinical BL and those who did not. A Wilcoxon rank sum test was used to test the association of the dosimetric parameters with clinical BL. We identified 268 patients who were eligible for the study. After chart and radiologic review, 119 patients had complete records available and were included in this study. Twenty-nine patients (24.4%) of the patients presented with symptomatic BL. Most patients (68%) received hypofractionated (42.56 Gy with or without 10 Gy boost), while 25% received conventional and 7% received ultra-hypofractionated radiotherapy. There was no association between the fractionation and incidence of BL (p = 0.4). There was no association between breast size and BL (mean 1065 cc vs 1232 cc, p = 0.35). There was significant association between BL and BS V30 (142cc vs 162 cc, p = 0.02), and BS V40 (82 cc vs 102 cc, p = 0.02), and a trend towards significant association with BS V20 (172cc vs. 193cc, p = 0.08), BS V50 (8 cc vs. 16 cc, p = 0.06). There was no significant association between BL and BS mean dose (36.9 Gy vs 39 Gy p = 0.11), or BS max dose (53.9 Gy vs 54.1 Gy, p = 0.21). None of the dosimetric parameters of WB and BE had significant association with clinical BL. Utilizing ROC analysis, there was significant association between clinical BL and the change of baseline mammogram breast skin thickness and skin thickness at 6 months follow up mammograms (+13 mm center point p = 0.04, +9 mm bottom point p<0.5), and at 12 months mammograms (+15 mm center point p<0.5, +11 mm bottom point p<0.5). Almost 1 in 4 women experienced radiation induced BL in our cohort. BS V30 & V40 are significantly associated with higher risk of BL. There was significant association between increased skin thickening in 6- and 12-months follow up mammograms and BL. Further analysis will follow to assess the association between surgical and clinical characteristics and BL.

Improving the Assessment and Diagnosis of Breast Lymphedema after Treatment for Breast Cancer.

Lymphedema can develop after treatment for breast cancer (BCRL). Lymphedema of the breast is not well studied. Currently, the main techniques used to diagnose and monitor the effectiveness of treatment are subjective clinician assessment and patient reports. Eighty-nine women who had undergone breast cancer treatment were recruited with and without breast lymphedema. Blinded clinical assessment determined the presence or absence of breast lymphedema. Measurement of skin thickness by ultrasound scanning, local tissue water by tissue dielectric constant (TDC) and tissue indentation by tonometry was recorded. Breast cancer treatment and demographic details were documented. Descriptive statistics were undertaken to compare sample characteristics, including the Chi-squared test, Odds Ratio (OR) and Relative Risks (RR) calculated. Increased body mass index (BMI), larger bra size, increased number of positive lymph nodes, axillary surgery, chemotherapy and increased Nottingham Prognostic Index (NPI) were all associated with breast lymphedema (p < 0.05). Ultrasound and TDC measurements were significantly higher in the lymphedema group (p < 0.05). Receiver Operator Characteristic (ROC) curves demonstrated that ultrasound and TDC measurements could distinguish between edematous and non-edematous breasts. Threshold levels were produced, which demonstrated good levels of sensitivity and specificity. These findings have the potential to improve the diagnosis of breast lymphedema.

"The Effectiveness of Manual Lymph Drainage (MLD) in Breast Lymphedema and Generalized Oedema after Mastectomy: A Case Study"

After a mastectomy a very common pathology for patients is to develop breast or arm lymphedema. The reasons are unknown. Lymphedema has described as a very uncomfortable situation that concerns many patients after mastectomy. Also, during chemotherapy these patients may develop generalized oedema, especially to the ankles, torso, and face. The most easy and painless way to treat this oedema is the Manual Lymph Drainage (MLD), with very good results to patient’s health.

Iatrogenic Breast Lymphoedema: Incidence, Diagnosis, and Associated Risk Factors.

While upper limb lymphoedema following breast and axillary surgery is well established in the literature, breast lymphoedema is rarely documented. Our primary objective was to identify risk factors of breast lymphoedema, and our secondary aim was to assess the possibility of using a breast ultrasound scan to assess breast lymphoedema. This study was a case series analysis, including patients who had wide local excision for primary breast cancer treatment between January 2013 and January 2018. Patients' demographics, including age, weight, body mass index (BMI), breast volume, tumour characteristics, and histological findings, were noted. All patients had a clinical assessment and ultrasound scan 6months and 12months after surgery, comparing ipsilateral to the contralateral breast skin, subcutaneous thickness, as well as parenchymal changes. We have included two hundred eighty-six breast cancer; the mean age was 54.7years SD 17.3, the mean weight was 76.5kg SD 12.6, the mean BMI was 31.5 SD 5.2, and the mean breast volume was 1223ml SD 179. This study identified breast lymphoedema in patients with clinically detected skin oedema in the absence of radiotherapy skin changes; skin and subcutaneous 5mm added thickness more than the contralateral side, and based on that, 22 patients (7.7%) were found to have breast lymphoedema. We have also found that patients with high BMI, larger breast volume, upper outer quadrant tumours, and patients who had axillary lymph node clearance had an increased incidence of breast lymphoedema. The incidence of breast lymphoedema in this cohort was 7.7%. We suggest that breast lymphoedema should be considered if skin and subcutaneous thickness are 5mm more than the contralateral side in the absence of severe radiotherapy skin changes. Also, we have found that high body mass index (BMI), larger breast volume, upper outer quadrant tumours, and patients who had axillary lymph node clearance are associated with an increased incidence of breast lymphoedema.

The effect of adjuvant radiotherapy on skin biophysical properties in patients with breast cancer at risk for breast lymphedema: A prospective study.

Breast cancer (BC) is the most common type of cancer among women. Radiotherapy (RT) is one of the main and primary treatment options for BC, especially in breast-conserving surgery (BCS). BC patients who underwent RT experience a wide range of symptoms, in which breast oedema and irritation of the skin take the lion's share. Breast oedema/lymphedema, which is also a prominent side effect after RT should be well determined in earlier settings due to the chronicity of lymphedema. Therefore, this study aimed to analyze the biophysical parameters of skin on the ipsilateral (IL) and contralateral (CL) sites via Tissue dielectric constant (TDC) and Transepidermal water loss (TEWL) methods in terms of oedema and skin barrier function (SBF). The following reference points before and after the RT were measured: (R1: Pectoralis muscle, R2: Upper breast, R3: Lower breast, R4: Lateral site of the thorax). A total of 24 BC patients (mean age and BMI: 52.78 ± 9.85 years and 28.42 ± 5.64 kg/m2 ) were evaluated. In the IL site, the SBF was not found significant in R1-R3, whereas significantly lower SBF was observed in R4 after RT (t = -3.361, p = 0.003). A significant increase in TDC was observed in R2 at the 5.0 mm depth (t = -2.500, p = 0.02). We suggest that a longer period of follow-up should be carefully carried out to track changes in terms of SBF and oedema in the irradiated breast. The increased need for early detection of changes associated with breast lymphedema can be achievable via noninvasive, safe, cheap, and easily repeatable devices.

Acute Effects of Manual Lymphatic Drainage and Compression with Exercise Therapy on Breast Lymphedema Following Breast-Conserving Surgery and Radiotherapy.

Background: Breast lymphedema is a common complication of breast cancer treatments but there are limited studies about the treatment of breast lymphedema. The aim of this study was to investigate the acute effects of manual lymphatic drainage (MLD), compression with exercise on the local tissue water percentage, pain, and stiffness following breast-conserving surgery and radiotherapy. Materials and Methods: Twenty-two patients (52.54 ± 12.18 years, 28.55 ± 5.11 kg/m2) were included. The sociodemographic and clinical information was recorded. The pain and stiffness severity were measured with Visual Analog Scale. Measurements of water percentages in local tissue were performed in all quadrants of the breast with the Moisture Meter D Compact device. All measurements were performed baseline, after MLD, and after compression with exercise. Results: There was a significant difference in local tissue water percentages between the affected and unaffected sides before treatment. The percentage of water only in the lower outer quadrant of the affected breast increased significantly after acute treatment (p: 0.002). In addition, pain (p: 0.001) and stiffness (p: 0.001) scores decreased. Conclusions: Local tissue water percentages increased with MLD and decreased with compression with exercise. In the treatment of breast lymphedema, MLD and compression bandage with exercise may be beneficial in the management of the symptoms of swelling, pain, and stiffness.

Reliability and Measurement Error of Breast Volume Calculation Using Three-Dimensional Surface Imaging.

Background: Breast lymphedema after breast cancer is challenging to quantify. Three-dimensional (3D) surface imaging is one available technique to measure breast volume, however, the measurement properties of available software programs have not been fully determined. The aim of this study was to determine equivalency of measurements with two software programs as well as reliability, standard error of measurement (SEM), and smallest detectable change (SDC). Methods and Results: Retrospective three-dimensional surface imaging (3D-SI) of 100 breasts taken before or after breast conserving surgery for breast cancer were retrieved for reliability analysis. Three assessors followed a standardized measurement technique using two software programs, Vectra® 3D Analysis Module (VAM) and Breast Sculptor®. Mean breast volume was 489.9 ± 206 cc using VAM and 480.1 ± 229.1 cc using Breast Sculptor. Lin's concordance showed poor agreement between programs (0.81-0.88). Measurements using VAM had excellent intra- and inter-rater reliability with SEM = 4.1% for one assessor and 8.7% for multiple assessors. Breast Sculptor also had excellent intra-rater and substantial inter-rater reliability but the SEM was much larger at 14.5% (intra-rater) and 19.1% (inter-rater). The SDC value was lowest for VAM and a single rater with 56 cc indicating a meaningful change beyond measurement error. Conclusion: Breast volume measurements captured with 3D-SI using VECTRA-XT are highly reliable, but the volumes, SEM, and SDC varied between the two software programs. Measurement error was lowest with VAM software. Although the usefulness of VECTRA-XT and VAM software to detect change in breast volume is promising, further solutions to reduce measurement error are required to improve clinical utility to measure breast lymphedema.

60. TRUNK LYMPHEDEMA FOLLOWING BREAST CANCER SURGERY: AN ANATOMIC AND FUNCTIONAL STUDY

PURPOSE: In the upper and lower extremities, ICG-lymphangiography has proven valuable in characterizing the lymph channel dysfunction (anatomic) and dermal backflow (functional) changes seen in early and late-stage lymphedema. We propose to use ICG-lymphangiography to evaluate if trunk and breast lymphedema occur following breast cancer surgery. METHODS: All patients undergoing second stage or revision surgery following breast reconstruction were offered ICG-based lymphangiography screening of upper extremities, chest, or breast. Twenty-nine patients selected chest and breast lymphangiography. 25 mg of indocyanine green (Akorn, Inc., Illinois) diluted in 10cc of sterile water was injected intradermally (0.1 cc) at the distal-most extent of the axillary drainage territory of each hemi-trunk. 60 minutes following injection, the breast and trunk were visualized with the PDE Neo II (Hamamatsu, Japan) using the fluorescence mode and evaluated using Koshima patterns of dermal backflow. RESULTS: 52 sides (29 patients) were included in the study. 8 sides underwent neither surgery nor radiation and were considered controls. No lymphedema was identified within the control cohort. Of the 42 non-control/functional transit sides, 35 sides (76%) had some form of dermal backflow abnormality. Severe dermal backflow (diffuse pattern) was seen most commonly in the anterior trunk (37%), lateral trunk (24%), and inferior breast (22%). CONCLUSION: We report clear evidence that following breast cancer surgery, lymphedema occurs throughout the trunk and breast. Severe dysfunction appears to be located around the inferior-lateral aspect of the breast and chest wall. This may explain post-mastectomy breast/chest wall heaviness and dysesthesia.

The Pittsburgh Trunk Lymphedema Staging System (PTLSS) – a validated staging system for the description of breast cancer-associated trunk lymphedema

Neither anatomic nor functional descriptions exist of trunk/breast lymphedema following breast cancer treatment. Indocyanine green (ICG)-lymphangiography has been shown to characterize lymph channel dysfunction seen in lymphedema. We propose using ICG-lymphangiography to evaluate trunk and breast lymphedema following breast cancer surgery to characterize the regions affected via a novel, validated staging system. Patients undergoing revisional breast surgery with suspicion of upper extremity lymphedema between December 2014 and March 2020 were offered lymphangiography. The breast and lateral/anterior trunks were visualized and blindly evaluated using Koshima's patterns of dermal backflow. Patients were then staged. A linear-weighted Cohen's kappa statistic was calculated comparing each rated area and stage assignment. Fifty-two sides (29 patients) were included. Eight sides underwent no treatment and were considered controls. No lymphedema was identified within this cohort. One patient (two sides) had no transit of ICG. Seventy-six percent of the non-controls had dermal backflow. This was seen in 67% of anterior trunks, 50% of lateral trunks, 50% of inframammary folds (IMFs), 43% of inferior breasts, and 5% of superior breasts. Cohen's kappa for area agreement was 0.4117 ± 0.0535. Stage 0 was seen in 31 (±7)% of sides; stage 1: 21 (±1)%; stage 2: 22 (±5)%; stage 3: 18 (±4)%; stage 4: 5 (±1)%; and stage 5: 4 (±0). Cohen's kappa for staging was 0.8109 ± 0.0868. Following breast cancer surgery, lymphedema occurs throughout the trunk and breast. Severe dysfunction appears to be located around the inferior-lateral aspect of the breast and chest wall. Furthermore, the Pittsburgh Trunk Lymphedema Staging System is a validated measure of trunk and breast lymphedema.

Abstract P3-18-15: Reliability and measurement error of breast volume calculation using 3D surface imagery

Abstract Introduction Breast volume measurement is important for oncoplastic surgery planning and measuring outcomes and side effects of both surgery and radiotherapy, including breast lymphedema. However, accurate breast volume quantification is difficult due to the shape of the breast and isolation of the breast border. Numerous techniques to quantify breast volume exist, but none have been established as a gold standard outcome measure. Three-dimensional (3D) surface imagery using VECTRA-XT can measure breast volume quickly and non-invasively. However, as measurement properties associated with quantification of breast volume using VECTRA-XT have yet to be fully determined, including extent of reliability, standard error of measurement (SEM), and smallest detectable change (SDC), the aim of this study is to determine these properties.Method A reliability study using retrospective VECTRA®-XT 3D surface images taken during clinical practice was conducted. Images from 51 women (101 breasts) before or after breast conserving surgery for breast cancer were retrieved for analysis. The breast images were taken pre-operatively in 70% of cases and following wide local excision in the remaining 30% of cases. Radiotherapy had also been performed in 20% of cases. Women were excluded if they had breast implants or mastectomy, had a breast ptosis grade of 3 (nipple was below the inferior mammary fold and close or below the lowest breast contour) or if the inferior mammary fold could not be visualised from any view of the 3D image. Three assessors trained using a standardised technique to use two software analysis programs, Vectra® 3D Analysis Module (VAM) and Breast Sculptor® software, completed the measurements. One assessor completed breast volume calculations twice (intra-rater reliability) and the remaining two assessors completed calculations once (inter-rater reliability). Results Mean breast volume for the population was 493.7cc (95%CI=469.4-517.9, range=135-1161cc) when measured by VAM and 488.7cc (95%CI= 461.2-516.2, range=104-1596cc) when measured by Breast Sculptor®. The difference in breast volume assessed using paired t-test was not statistically significant (p=0.491). Measurement of breast volume using VAM had excellent intra and inter-rater reliability with a SEM of less than 5.0% for a single rater and less than 9.0% for multiple raters. In comparison, Breast Sculptor® had excellent intra-rater reliability and substantial inter-rater reliability but the SEM was 14.3% and 20.5% for intra and inter-raters respectively (Table 1). A single rater using VAM software had the lowest SDC value indicating a change in breast volume exceeding 58.6cc would be a meaningful change in breast volume beyond measurement error. Conclusion The reliability for the assessment of breast volume using VECTRA-XT 3D surface imagery was high when a standardised approach was used. However, the SDC, i.e. the amount of change beyond error of measurement, varied depending on which program was used and whether one or more than one rater assessed the volume. A single assessor using VAM software should be considered as the ideal in. evaluation of changes in breast volume secondary to edema, as the SDC is likely too large to detect changes using the other approaches. The project was funded by a Betty Schofield and Joyce Anderson Bequest Grant. Table 1.Reliability, standard error of measurement and smallest detectable changeICC (95% CI)Standard error of measurement (cc)Standard error of measurement %Smallest detectable change (cc)VAM Inter-rater reliability0.961 (0.943-0.973)42.78.7118.4VAM Intra-rater reliability0.990 (0.986-0.993)21.14.258.6Breast Sculptor® Inter-rater reliability0.837 (0.785-0.880)100.220.5277.7Breast Sculptor® Intra-rater reliability0.915 (0.876-0.942)74.014.3205.2 Citation Format: Nicola Rachel Fearn, Farid Meybodi, Sharon Kilbreath, Elizabeth Dylke, Catalina Llanos, Kirsty Stuart. Reliability and measurement error of breast volume calculation using 3D surface imagery [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-18-15.

Indocyanine Green Lymphography for Evaluation of Breast Lymphedema Secondary to Breast Cancer Treatments.

Although breast lymphedema (BL) significantly deteriorates quality of life (QOL) of breast cancer survivors, little is known and pathophysiological severity staging system is yet reported. This study aimed to evaluate usefulness of a novel BL severity staging system based on indocyanine green (ICG) lymphography findings. Breast cancer survivors with breast symptoms who underwent breast ICG lymphography were included. Breast ICG lymphography stage was determined based on visibility of linear pattern and extension of dermal backflow patterns. Prevalence of breast symptoms and lymphedema QOL score (LeQOLiS) was compared according to the stage. Thirty-seven patients were included. Breast ICG lymphography stage included stage 0 in 11 (29.7%) cases, stage I in 3 (8.1%) cases, stage II in 11 (29.7%) cases, stage III in 6 (16.2%) cases, stage IV in 4 (10.8%) cases, and stage V in 2 (5.4%) cases. Higher ICG stages were associated with more frequent prevalence of breast swelling (p = 0.020), breast pain (p = 0.238), and breast cellulitis (p = 0.024), and with higher LeQOLiS (p < 0.001). ICG lymphography allows clear visualization of superficial lymph circulation in the breast. Higher breast ICG lymphography stages are associated with more frequent prevalence of BL-related symptoms and worse QOL.

Indocyanine green utility in prevention and treatment of breast lymphedema

Breast cancer represents the most commonly encountered malignancy in women worldwide. In the last decades, due to the improvement of the imagistic techniques and to the wide implementation of screening tests, a significant number of cases are suitable for conservative surgery therefore improving the quality of life. Although the postoperative morbidity after breast conservative surgery is reduced, the procedure can still be associated with certain complications such as breast lymphedema, or wound difficult healing. The aim of the current paper is to discuss the possibility of prevention and treatment of breast lymphedema by using innovative techniques such as indocyanine green.

Ultrasound for the Objective Measurement of Breast Lymphedema.

Breast lymphedema has supplanted upper extremity lymphedema as a common and debilitating sequela of breast cancer treatment, but has no objective measurement. We assessed the utility of ultrasound-measured difference in dermal thickness between affected and unaffected breasts as a measure of breast lymphedema. We associated this measure with patient characteristics, treatment parameters, and patient-reported impact on quality of life. We enrolled 30 invasive breast carcinoma patients treated with breast-conserving surgery, sentinel lymph node biopsy, and radiotherapy, and 10 control patients evaluated for benign breast conditions without prior breast surgery or radiotherapy. Patient and treatment variables were ascertained from medical records and radiotherapy instruments. Impacts on quality of life were measured with a modified Disability of the Arm, Shoulder, and Hand questionnaire. We characterized breast lymphedema by calculating the difference in ultrasound-measured dermal thickness between affected and unaffected breasts. Associations with patient characteristics, treatment, and quality of life were quantified with log-binomial regression models. Breast lymphedema was defined as a dermal thickness difference of >0.3 mm. Nineteen patients in the invasive group (63%) had breast lymphedema by this definition. We observed positive associations between ultrasound-defined breast lymphedema and surgical factors (size of primary tumor, number of lymph nodes removed), radiotherapy factors (breast volume irradiated, receipt of radiation boost), and patient-reported outcomes (sleep quality and overall confidence). Difference in dermal thickness is an easy and inexpensive measurement for quantifying breast lymphedema, and correlates with treatment parameters and patient-reported impacts on quality of life.

A Pilot Study to Quantify Breast Lymphedema for Patients Undergoing Breast Conserving Therapy (BCT) for Breast Cancer

<h3>Purpose/Objective(s)</h3> Upper extremity lymphedema after axillary lymph node dissection and radiation for breast cancer has been well described and studied. As modern treatment techniques have reduced the incidence of arm lymphedema, breast lymphedema has emerged as a common result of BCT and is associated with poor wound healing, infection and impact on quality of life. Because there is no established tool for its evaluation and quantification, we explored the feasibility of using ultrasound to measure breast lymphedema objectively. We evaluated whether this measure correlated with clinical assessment, treatment factors, and patient-reported outcomes. <h3>Materials/Methods</h3> We enrolled 30 women with malignant breast cancer treated with breast conserving surgery, sentinel lymph node biopsy, and breast radiation. Another 10 women with benign disease who had not undergone BCT were sampled as controls. Ultrasound measurements of dermal thickness were performed on the treated breast and untreated breast at the 6:00 position. Post-treatment assessments included physical exam and quality of life DASH questionnaire. We quantified breast lymphedema as the dermal thickness of the affected breast minus the dermal thickness of the unaffected breast. Breast lymphedema was considered present if dermal thickness difference was above the highest-observed value in the benign patients. <h3>Results</h3> Mean age (± SD) was SD 59 ± 13 in the malignant group and 46.4 ± 17 in the benign group and groups were similar with regard to body mass index. Mean dermal thickness difference was higher in the malignant group compared with the benign group (1.03 mm and 0 mm, respectively). Seventy percent of patients in the malignant group met our definition of breast lymphedema (n = 21) and were more likely to report impact on quality of life pertaining to sexual activity (24% vs 11%), breast sensation (52% vs 16%), sleep quality (33% vs 21%) and confidence (24% vs 5%) than patients without breast lymphedema. Extent of axillary surgery was associated with a 1.29 mm increase in difference in dermal thickness for patients with > = 4 nodes removed (95% CI: -0.22, 2.80). The volume of breast tissue radiated was also positively associated, with every 100cc increase in breast volume radiated associated with a 0.17mm greater dermal thickness difference (95% CI: 0.04, 0.30mm). However, there was no association with percent of breast tissue receiving > 105% of prescribed dose (95% CI: -0.07, 0.01), hypofractionation vs. standard fractionation (95% CI: -1.2, 0.68) or total radiation dose (95% CI: -0.5, 1.2). <h3>Conclusion</h3> Breast lymphedema is an impactful sequela of breast cancer treatment but remains understudied with no standard measurement tools. Our pilot study demonstrates that ultrasound is a promising tool for the characterization of breast lymphedema and may improve our understanding of patient and modifiable treatment risk factors.

Ultrasound: Assessment of breast dermal thickness: Reliability, responsiveness to change, and relationship to patient-reported outcomes.

The current study assessed the level of reliability of ultrasound to assess dermal thickness, a clinical feature of breast lymphedema. Additionally, the relationship of dermal thickness to patient-reported outcomes was investigated. Women (n=82) with unilateral breast edema secondary to treatment of breast cancer were randomized to an exercise or control group. Ultrasound measurements of the unaffected and affected breasts were taken at baseline and 12weeks later at 3-4cm superior, medial, inferior, and lateral to the nipple. Additionally, women completed breast-related questions from the European Organization Research and Treatment Committee Quality of Life breast cancer module (EORTC-BR23) and Lymphedema Symptom Intensity and Distress Questionnaire (LSIDS). Reliability of ultrasound measurements was determined on the unaffected breast. Intraclass correlation coefficients (2,1) ranged from 0.66 (95% CI: 0.52-0.77) for the lateral location to 0.84 (0.77-0.90) for the superior location. Percent close agreement (80%) on the unaffected breast ranged from 0.20 to 0.27mm compared to 0.57 to 0.93mm on the affected breast. The standard error of measurement (%) on the unaffected breast varied from 9% to 13% with smallest real difference 0.34-0.41mm. Dermal thickness of the affected breast was not-to-poorly associated with EORTC BR23 and LSIDS scores. Reliability of dermal thickness measurements of the breast was excellent for the superior, medial, and inferior locations, and fair to good for the lateral location. However, these measurements were not related to the symptom's women perceive and measured with the EORTC BR23 or LSIDS.

How the COVID-19 Quarantine Will End the Breast Cancer Epidemic

The problem with bras is that they are designed to change breast shape for fashion reasons, and this requires constant tension and pressure from the bra. This pressure impairs the lymphatic circulation in the breasts, which is the circulatory pathway of the immune system. This causes lymph stasis and chronic breast lymphedema, and prevents effective immune defense against developing cancer cells. It also prevents the effective cleansing of the breasts of cellular waste, debris, chemical toxins, and the damage caused by trauma and radiation (such as mammograms). See the article, How Bras Cause Lymph Stasis and Breast Cancer.