Risk Of Lymphedema Research Articles

Critically appraised paper: For women at high risk of breast cancer-related lymphoedema, prophylactic compression sleeve usage reduces and delays occurrence of arm swelling [commentary

Critically appraised paper: For women at high risk of breast cancer-related lymphoedema, prophylactic compression sleeve usage reduces and delays occurrence of arm swelling [commentary

Frequency of Lymphedema after Complete Axillary Lymph Node Dissection in Patients with Breast Cancer

Objective: To assess the frequency of lymphedema of the arm and forearm after complete axillary lymph node dissection in patients with breast cancer at one year of follow-up and see its association with body mass index among breast cancer patients presenting at a tertiary care hospital in Karachi.
 Study Design: Prospective longitudinal study.
 Place and Duration of Study: Department of Medical Oncology, Jinnah Postgraduate Medical Center, Karachi, Pakistan, from Apr 2019 to 2020.
 Methodology: One sixty-eight females of age 25-80 years who underwent complete axillary lymph node dissection for breast cancer were included in the study. A breast surgeon performed the axillary lymph node dissection with more than five years of experience. The patients were followed for one year post-operatively to determine the occurrence of lymphedema. All the demographic details and clinic-pathological findings were reported in the predesigned proforma.
 Results: About 168 females (97.6%) out of 172 have undergone complete axillary lymph node dissection. Lymphedema was the most common complication among them (38.1%). Common side effect observed after axillary lymph node dissection was pain (66.1%), followed by heaviness (59.5%), firmness/tightness (46.4%) and numbness. The patients with Body mass index ≥ 25 kg/m2, right arm involved, exposure to radiotherapy and moderately differentiated tumour (grade-2) had a significantly higher occurrence of lymphedema (p<0.05).
 Conclusion: Lymphedema is higher among breast cancer survivors during the first postoperative year. The risk of lymphedema can be reduced by avoiding potential factors like obesity and carefully selecting patients for postoperative radiotherapy.

Comparison of machine learning models for predicting the risk of breast cancer-related lymphedema in Chinese women

ObjectivePredictive models for the occurrence of cancer symptoms by using machine learning (ML) algorithms could be used to aid clinical decision-making in order to enhance the quality of cancer care. This study aimed to develop and validate a selection of classification models that used ML algorithms to predict the occurrence of breast cancer-related lymphedema (BCRL) among Chinese women. MethodsThis was a retrospective cohort study of consecutive cases that had been diagnosed with breast cancer, stages I-IV. Forty-eight variables were grouped into five feature sets. Five classification models with ML algorithms were developed, and the models' performance and the variables’ relative importance were assessed accordingly. ResultsOf 370 eligible female participants, 91 had BCRL (24.6%). The mean age of this study sample was 49.89 (SD ​= ​7.45). All participants had had breast cancer surgery, and more than half of them had had a modified radical mastectomy (n ​= ​206, 55.5%). The mean follow-up time after breast cancer surgery was 28.73 months (SD ​= ​11.71). Most of the tumors were either stage I (n ​= ​49, 31.2%) or stage II (n ​= ​252, 68.1%). More than half of the sample had had postoperative chemotherapy (n ​= ​227, 61.4%). Overall, the logistic regression model achieved the best performance in terms of accuracy (91.6%), precision (82.1%), and recall (91.4%) for BCRL. Although this study included 48 predicting variables, we found that the five models required only 22 variables to achieve predictive performance. The most important variable was the number of positive lymph nodes, followed in descending order by the BCRL occurring on the same side as the surgery, a history of sentinel lymph node biopsy, a dietary preference for meat and fried food, and an exercise frequency of less than three times per week. These factors were the most influential predictors for enhancing the ML models’ performance. ConclusionsThis study found that in the ML training dataset, the multilayer perceptron model and the logistic regression model were the best discrimination models for predicting the outcome of BCRL, and the k-nearest neighbors and support vector machine models demonstrated good calibration performance in the ML validation dataset. Future research will need to use large-sample datasets to establish a more robust ML model for predicting BCRL deeply and reliably.

Lymphedema therapy referral is associated with improved understanding of lymphedema prevention among breast cancer survivors.

12069 Background: Lymphedema is common among breast cancer survivors (BCS) and negatively affects quality of life. There are modifiable factors to reduce lymphedema risk and exacerbation; it is unknown how aware survivors are of these factors. We hypothesized referral to lymphedema therapy (LT) to be associated with improved lymphedema knowledge. Methods: BCS were approached during follow-up visits at an NCI-designated cancer center between 2014-2015 and asked to complete an anonymous survey. Eligibility criteria: age ≥18, English-speaking, > 6 months post-surgery, no cancer recurrence, no prior or subsequent second cancer. Surveys included 10 true/false questions to assess beliefs of common lymphedema misconceptions and questions about sociodemographics, cancer treatment, and prior LT referral. Charts were reviewed to determine history of axillary lymph node dissection (ALND) or sentinel node biopsy (SLNB). Multivariable logistic regression assessed the relationship between prior LT referral and correctly answering questions about lymphedema misconceptions. Results: Of 209 participants, 67% identified as non-Latinx white, 13% Black, 10% Latinx and 8% Asian. 53 (25%) had been referred to LT. Those who had SLNB were less frequently referred to LT [15 (14%)] than those who had ALND [38 (39%)]. There were 5 lymphedema knowledge questions with < 80% correct responses (Table). Those previously referred to LT more often correctly answered the questions about weight gain and using the arm on an airplane than those not referred (chi-2: p <0.01 and p < 0.01), but they were less likely to answer correctly about carrying > 10 lbs or strenuous activity at work (p < 0.01 and p = 0.02, respectively) (Table). These associations remained in multivariable analyses, other than strenuous work activity (Table). Conclusions: We identified several misconceptions regarding lymphedema among BCS. LT referral is a potential opportunity to debunk common misunderstandings regarding lymphedema risk reduction; providers should have a low threshold to refer patients. Lymphedema therapists teach progressive exercise strategies, which may have inadvertently caused participants to think they should avoid carrying objects > 10 lbs.[Table: see text]

Dietary supplements in lymphedema.

Lymphedema is a chronic inflammatory disorder resulting from ineffective fluid uptake by the lymphatic system, and the effects are principally felt in the lower limbs. The condition is said to be primary when caused by genetic mutations and secondary when caused by injuries, infections, or surgery. Lymphedema, a worldwide pathology, does not have an effective therapy so far. Leukotriene B4 has recently been identified as a key molecule in lymphedema pathogenesis. Surgical, nonsurgical, and pharmacological treatments have been proposed; however, they do not cure the disease and only ameliorate the symptoms. Nutrition and nutritional status are extremely important in lymphedema physiopathology. Obesity is a comorbidity that exacerbates the risk for secondary lymphedema and constitutes a negative prognostic factor. Indeed, anti-inflammatory foods and their effects on the inflammatory state and on oxidative stress are now being investigated for their possible therapeutic role in lymphedema. Although no special diet has so far been proven to be very effective, specific dietary tips could help in alleviating the edematous state of patients with lymphedema. A few supplements have been tested for lymphedema treatment. Among them, GARLIVE® containing hydroxytyrosol, hesperidin, spermidine and vitamin A, exhibited promising effects in the animal model. Hydroxytyrosol, a polyphenol from olives, showed anti-inflammatory effects and reduced leukotriene B4 synthesis, thus holding promise as a potential natural candidate for lymphedema treatment.

Illness perceptions and adherence to breast cancer-related lymphedema risk management behaviours among breast cancer survivors.

To describe illness perceptions of breast cancer-related lymphedema (BCRL) and adherence to BCRL risk management behaviours and analyse the relationship between these factors in postoperative breast cancer survivors in China. A cross-sectional study was conducted in the first half of 2019 using 281 breast cancer survivors. Participants' illness perceptions and adherence to BCRL risk management behaviours at the 3rd month after surgery were investigated using the Revised Illness Perception Questionnaire for BCRL (IPQ-R [BCRL]), Lymphedema Risk Management Behaviour Questionnaire (LRMBQ), and Functional Exercise Adherence Scale (FEAS). The relationship between these variables was studied using correlation analysis and multiple linear regression analysis. Among the four dimensions of the LRMBQ, the mean score of our respondents received in "skin care" was 3.63 (S.D. 0.67), which was the lowest on the dimension, demonstrating the worst performance in this aspect. Regarding the FEAS results, better functional exercise adherence was observed in our sample compared to previous Chinese research. The results also showed that adherence to BCRL risk management behaviours was related to patient age and degree of education. Furthermore, other dimensions of illness perceptions, such as consequence, timeline acute/chronic, illness coherence and identity, follow their multiple linear regression equations with their corresponding BCRL risk management behaviour adherence. Our findings confirmed the importance of illness perceptions for adherence to BCRL risk management behaviours, suggesting that we need to pay attention to patients' cognition in this respect and supply necessary interventions.

High recurrence of lymphedema and influencing factors in discharged breast cancer patients during the COVID-19 pandemic: A multicenter, cross-sectional survey.

BackgroundThere has been a delay in the detection and treatment of lymphedema in breast cancer patients during the lockdown owing to quarantine and limited social activity. Moreover, this scenario has caused psychosocial issues in these patients. Given that there is scarce information on the prevalence and influence of lymphedema during the coronavirus disease (COVID‐19) pandemic, we aimed to estimate the prevalence of lymphedema recurrence and its influencing factors among discharged breast cancer patients during the COVID‐19 pandemic.MethodsThis was a multicenter, cross‐sectional, hospital‐based survey of discharged breast cancer patients was conducted during the COVID‐19 pandemic in eight first‐class hospitals in Wuhan, China. The Norman Questionnaire was used to assess lymphedema. Univariable and multivariable binary logistic regression analyses were performed to identify factors influencing moderate or severe lymphedema. Differences in living characteristics, anxiety, and depression were compared between the no/mild lymphedema group and the moderate/severe lymphedema groups. Preferences for lymphedema management during the pandemic were determined.ResultsOverall, 202 patients were included in this study, and 191 of them reported recurrent lymphedema (prevalence: 94.6%, 95% confidence interval [CI] 90.5% to 97.3%). Among them, 134 and 57 had mild and moderate/severe lymphedema, respectively. In 191 patients, the main symptoms were swelling (140; 69.3%) and pain (56, 27.7%). Multivariable regression showed that older age (odds ratio [OR], 1.06; 95% CI: 1.02–1.10), radical surgery (OR = 4.35, 95% CI: 1.54–12.50), and fully complete radiotherapy (OR = 2.62, 95% CI: 1.17–5.87, p = 0.019) were associated with an elevated risk of moderate/severe lymphedema. The moderate/severe lymphedema group experienced a higher rate of anxiety and depression than the no/mild lymphedema group did. Patients equally preferred treatment in the hospital and self‐care at home.ConclusionDuring the COVID‐19 pandemic, high prevalence of lymphedema was observed in patients Age, radical surgery and fully completed radiotherapy were associated with increased risk of severer lymphedema. Meanwhile, the patients with severe lymphedema experienced psychological distress. While the Covid‐19 pandemic was still raging, continuous efforts should be made to identify patient at risk of lymphedema and distribute feasible guidance and education for self‐management in lymphedema.

Risk Factors for the Development of Clinical and Subclinical Lymphedema Detected by Bioimpedance Spectroscopy

Breast cancer-related lymphedema can significantly compromise quality of life. Bioimpedance spectroscopy (BIS) measures extracellular fluid in lymphedema. The purpose of this study was to determine the incidence of BIS-detected lymphedema using the L-Dex and identify risk factors associated with a positive score. We performed a retrospective review of our institutional database to identify patients who underwent L-Dex U400 measurements. Patients with a score of > 10 L-Dex units or with an increase of > 10 units from baseline had a positive score. Clinical lymphedema was determined by documentation in the chart at the time of positive measurement. Otherwise, patients were considered to have subclinical lymphedema. Fifty-three patients met study criteria. Thirty patients (56.6%) underwent mastectomy, 22 (41.5%) axillary lymph node dissection (ALND), and 33 (62.3%) received radiation (RT). Twelve patients (22.6%) had a positive score. There were no differences in age, race, laterality, breast surgery, T stage, N stage, chemotherapy, or RT fields (none, breast only, breast with LNs) in patients with a positive score. ALND was more common (66.7% vs. 34.2%, P= .04). BMI > 30 approached significance (58.3% vs. 29.3%, P= .06). Seven patients had subclinical lymphedema. No differences were identified comparing patients with subclinical lymphedema to those with negative scores. All 5 patients with clinical lymphedema underwent ALND and received nodal RT. The combination of ALND and regional nodal RT is strongly associated with development of clinical lymphedema. It is difficult to identify patients at risk for subclinical BIS-detected lymphedema.

Using the Indocyanine Green (ICG) Lymphography to Screen Breast Cancer Patients at High Risk for Lymphedema.

Background: Indocyanine green (ICG) lymphography is a newer technique for diagnosing lymphedema. Our study aimed to find whether the abnormality of ICG lymphography can predict the occurrence of early lymphedema and then select candidates at high risk of developing lymphedema. Methods: Postoperative breast cancer patients who visited the lymphedema clinic of Peking University People’s Hospital from December 2016 to September 2019 were consecutively enrolled and received ICG lymphography and circumference measurement. Data were collected on the patients’ characteristics and correlation between ICG lymphography and the occurrence of lymphedema. Results: The analysis included 179 patients. There were 91 patients in the lymphedema group and 88 patients in the non-lymphedema group. By multivariate analysis, age, axillary surgery, radiotherapy, and time since breast cancer surgery were regarded as risk factors for lymphedema (p < 0.05). According to the results of ICG lymphography, patients in the non-lymphedema group (n = 88) were divided into ICG-positive (n = 47) and ICG-negative (n = 41) groups. The incidence of lymphedema in the ICG-positive group was significantly higher than that in the ICG-negative group (19.1% vs. 2.4%, p = 0.027). Conclusion: Lymphatic disorder can be detected before circumference change using ICG lymphography. Abnormal ICG lymphography is an independent risk factor for lymphedema. Patients with abnormal dermal backflow patterns are considered to be a high-risk group for lymphedema and should undergo early interventions to prevent lymphedema.

2. LONG-TERM PROSPECTIVE SAFETY AND EFFICACY OF VASCULARIZED LYMPH NODE TRANSPLANT (VLNT)

PURPOSE: Despite the increasing popularity of vascularized lymph node transplant (VLNT), there is lack of prospective long-term outcomes data and standardized outcome metrics, specifically following Vascularized Omentum Lymphatic Transplant (VOLT). The purpose of this IRB-approved prospective study was to evaluate the long-term outcomes of VLNT using a comprehensive set of outcome measures. METHODS: All patients underwent VLNT at our institution between November 2014 and July 2020. Demographic data, volume measurements, bio-impedance scores, Quality of Life scores and cellulitis episodes were recorded. RESULTS: A total of 89 patients with a mean follow-up time of 23.7±12 months were included. Donor sites consisted of the omentum (73%), axilla (13%), supraclavicular (7%), groin (3.5%), and others. 20% decrease (p=0.0239) in volume differential, and 27.5% decrease (p=0.0398) in L-DEX scores were recorded 2 years after VLNT. A significant improvement in Lymphedema Life Impact Scale (LLIS) scores manifested as 28.4% decrease (p=0.0398) was recorded 2 years after treatment. In addition, VLNT dramatically decreased the total number of cellulitis episodes by 93% (p=0.0008) 1 year after treatment as well as the average number of episodes per year (84.5% decrease, p=0.0002). No cases of donor site lymphedema were recorded (0%). CONCLUSION: This prospective study demonstrated satisfactory reduction in limb volume, bioimpedance, and improved quality of life. This is the largest long-term prospective study of VOLTs in comparison to most studies evaluating peripheral VLNT. VOLT is a reliable alternative to peripheral VLNT with no risk of donor site lymphedema and particularly significant impact in reducing the incidence of cellulitis.

P58. RISK OF POST MASTECTOMY LYMPHEDEMA IN AUTOLOGOUS BREAST RECONSTRUCTION: A MULTI-CENTER 10-YEAR ANALYSIS OF 9,660 PATIENTS STRATIFIED BY FLAP-TYPE AND TIMING OF RECONSTRUCTION

PURPOSE: Following mastectomy, over 20% of women experience lymphedema. Previous studies suggest a possible protective effect of breast reconstruction against lymphedema development. This study analyzes risk of developing post-mastectomy lymphedema following autologous reconstruction by flap-type and temporality using a real-time, federated electronic medical record network (TriNetX Inc, Cambridge, MA). METHODS: 85,776,922 de-identified patient records were retrospectively screened from 2006-2021. 60,157 post-mastectomy patients aged 18-99 met criteria and were allocated into paired cohorts using common procedural terminology codes. Cohorts were then compared to assess lymphedema outcomes relative to timing (immediate vs. delayed) and flap-type (DIEP/TRAM/latissimus). Paired cohorts were compared and stratified by timing of reconstruction. Outcomes were assessed following stringent balancing for age, race, radiation, chemotherapy, hormone therapy, smoking, diabetes, obesity, and axillary lymph node dissection. Post-operative lymphedema rates within 2, 5, and 10-years of mastectomy were analyzed. RESULTS: DIEP and latissimus patients demonstrated significantly decreased risk of lymphedema compared to mastectomy without reconstruction across all time points; DIEP (Risk Ratio (RR): 0.487-0.546, 95% Confidence Interval (95%CI): 0.411-0.651,p<0.001), latissimus (RR:0.567-0.638,95%CI:0.423-0.828],p<0.001). Delayed DIEP was associated with significantly reduced post-mastectomy lymphedema risk versus immediate DIEP reconstruction within 10 years (0.639-0.652[0.459-0.889], p<0.01). CONCLUSION: Our analysis examines the potential protective effect against lymphedema of various approaches to autologous breast reconstruction. Limitations include this study’s retrospective nature and reliance on medical coding. Future prospective studies are warranted to confirm whether autologous breast reconstruction, and specifically delayed DIEPs, may be protective against post-mastectomy lymphedema.

Lymphedema After Axillary Lymph Node Dissection in Breast Cancer: Prevalence and Risk Factors-A Single-Center Retrospective Study.

Background: Lymphedema may develop when axillary lymph node dissection (ALND) injures and obstructs the lymph ducts in the upper limb. In patients with breast cancer, lymphedema is difficult to treat and can cause arm swelling, heaviness, and restricted movement. We aimed to identify the prevalence and risk factors for lymphedema after ALND in patients with breast cancer. Methods and Results: This retrospective study included 175 patients with breast cancer who underwent ALND in the Nagasaki University Hospital, Japan, between 2005 and 2018. Lymphedema was defined as symptomatic arm swelling with a >2-cm difference in the arm circumference between the affected and contralateral arms. Patients were divided into two groups according to the presence or absence of lymphedema. Surgical and pathological findings were compared between the two groups. Univariate and multivariate analyses were performed, including the chi-square test, Student's t-test, and logistic regression analysis. Lymphedema was prevalent in 20% of the study participants, and the mean time interval from surgery to development of lymphedema was 479 days. In the univariate analysis, a body mass index of >26 kg/m2, smoking, radiotherapy (RT), and dissection of >18 axillary lymph nodes (ALNs) significantly increased the risk of lymphedema. In the multivariate analysis, smoking, RT, and dissection of >18 ALNs significantly increased the risk of lymphedema. Conclusions: The prevalence of lymphedema in our study was 20%. Our findings suggest that smoking, RT, and dissection of >18 ALNs are risk factors for lymphedema. Aggressive and empiric ALND might be associated with axillary lymph duct damage.

Effect of Supervised Resistance Training on Arm Volume, Quality of Life and Physical Perfomance Among Women at High Risk for Breast Cancer-Related Lymphedema: A Study Protocol for a Randomized Controlled Trial (STRONG-B).

ObjectivesTo determine the preventive effects of supervised resistance training on arms volume, quality of life, physical performance, and handgrip strength in Chilean women at high risk for breast cancer-related lymphedema (BCRL) undergoing chemotherapy.DesignRandomized control trial.ParticipantsOne hundred and six women at high risk for breast cancer-related lymphedema aged 18 to 70 years.InterventionsParticipants will be randomized into two groups: [a] intervention, who will receive 12 weeks of supervised resistance training (STRONG-B) during adjuvant chemotherapy; and [b] control, who will receive education to promote lymphatic and venous return, maintain range of motion, and promote physical activity.Main Outcome MeasuresThe primary outcome will be arms volume measured with an optoelectric device (perometer NT1000). Secondary outcomes will be quality of life, handgrip strength, and physical performance. Primary and secondary outcomes will be measured at baseline, just after the intervention, and 3 and 6 months after. Statistical analysis will be performed following intention-to-treat and per-protocol approaches. The treatment effect will be calculated using linear mixed models.DiscussionThe STRONG-B will be a tailored supervised resistance training that attempts to prevent or mitigate BCRL in a population that, due to both intrinsic and extrinsic factors, will commonly suffer from BCRL.Clinical Trial Registration[https://clinicaltrials.gov/ct2/show/NCT04821609], identifier NCT04821609.

ICG lymphographic findings following immediate lymphatic reconstruction in breast cancer patients

Immediate lymphatic reconstruction (ILR), performed at the time of axillary lymph node dissection (ALND), has demonstrated promising reductions in breast cancer-associated lymphedema. However, questions remain over the effects of adjuvant therapies on the continued patency of the lymphaticovenous anastomosis. Our study aimed to assess lymphographic outcomes, including ICG pattern and LVB patency, in patients at high risk for breast cancer-associated lymphedema following axillary ILR. Baseline ICG lymphography studies performed during ILR of 15 patients were compared to repeat ICG studies obtained during second-stage breast reconstructive procedures to assess for changes in lymphatic flow patterns through the at-risk arm and transit into the axilla. All 15 patients in this study demonstrated linear lymphatic flow in baseline lymphography. Repeat lymphographic studies showed linear lymphatic transit in 12/15 patients. Of these 12 patients, 10 received chemotherapy, and all 12 received post-mastectomy radiation (PMRT). Dermal backflow patterns were recorded in 3/15 patients. All 3 patients received chemotherapy and 2/3 underwent PMRT. Additionally, repeat ICG studies of 7/12 lymphedema-free patients demonstrated clear visualization of linear ICG flow from the lymphatics of the arm into the axilla. We have demonstrated that ICG lymphography can be implemented as a postoperative tool to assess lymphatic function in patients who have undergone ILR in the axilla. Repeat ICG studies in the majority of patients demonstrated linear ICG flow similar to baseline studies. Additionally, ICG flow patterns through the axilla in repeat lymphography provided visual evidence supporting sustained LVB patency, despite axillary irradiation.

Immediate Lymphatic Reconstruction to Prevent Breast Cancer-Related Lymphedema: A Systematic Review.

Significance: Lymphedema is chronic limb swelling from lymphatic dysfunction. The condition affects up to 250 million people worldwide. In breast cancer patients, lymphedema occurs in 30% who undergo axillary lymph node dissection (ALND). Recent Advances: Immediate lymphatic reconstruction (ILR), also termed Lymphatic Microsurgical Preventing Healing Approach (LyMPHA), is a method to decrease the risk of lymphedema by performing prophylactic lymphovenous anastomoses at the time of ALND. The objective of this study is to assess the risk reduction of ILR in preventing lymphedema. Critical Issues: Lymphedema has significant effects on the quality of life and morbidity of patients. Several techniques have been described to manage lymphedema after development, but prophylactic treatment of lymphedema with ILR may decrease risk of development to 6.6%. Future Directions: Long-term studies that demonstrate efficacy of ILR may allow for prophylactic management of lymphedema in the patient undergoing lymph node dissection.

Abstract P4-11-22: Arm lymphedema and socioeconomic factors in an urban cancer center

Abstract Introduction. Socioeconomic and racial factors have been reported as influencing breast cancer outcomes. Low income and African American race are associated with worse outcomes after a breast cancer diagnosis. Lymphedema is a common side effect of cancer treatment, occurring in approximately 25-60% of patients who undergo axillary dissection with or without radiation. In our urban, heavily African American population, we examined socioeconomic risk factors for arm lymphedema development. Methods. 176 women were enrolled before surgery for stage 0-III breast cancer. Baseline interviews were conducted, including job descriptions, income, ethnic background, marital status, weight, and medical comorbidities. Pathologic stage as well as treatment regimen including receipt of radiation to the axilla were also recorded. Baseline arm measurements were also taken. Arm measurements were repeated at intervals of 3 months up to 2 years, and any increase &amp;gt;5% was classified as lymphedema. Median follow-up was 2 years. Results. Cox regression was used to identify patient factors associated with lymphedema development. Median age at enrollment was 51 (29-86). 46% of patients enrolled were Caucasian, and 42% were African American. 11% had carcinoma in situ, 33% had stage I, 42% had stage II, and 14% had stage III breast cancer at presentation. 68% of patients were overweight or obese at presentation. Of the patients who had income data available, 30% had income &amp;gt;$50,000 per year, 15% had income $15,000-50,000 per year, and 24% of patients had income &amp;lt;$15,000 per year. 45% of patients were married or cohabitating with a partner, 38% were divorced and 13% were single. 20% of patients were not working outside the home at the time of enrollment, 49% had jobs that involved office work, and 23% had jobs that involved manual labor. Job descriptions classified as involving manual labor were associated with higher risk of lymphedema (p=0.033). Higher body mass index (≥30), total mastectomy, and axillary dissection (removal of ≥9 nodes) were significantly associated with development of lymphedema (p&amp;lt;0.05). Divorced status showed a trend towards association with lymphedema but was not statistically significant (p=0.08) Sentinel node biopsy with axillary sampling was not a risk factor for lymphedema development. Race was not associated with lymphedema development. Very low income (United States Housing and Urban Development classification &amp;lt;$15,000 at the time of the study) was not significantly associated with higher risk of lymphedema. Conclusion. Higher body mass index and more extensive surgical intervention are known risk factors for lymphedema development. Our study findings also showed an association between these known risk factors and lymphedema development. There has been conflicting evidence about weight lifting and arm lymphedema development in the past. A previous report from Schmitz et al. in the New England Journal of Medicine showed no association of slowly progressive weight lifting with lymphedema risk. Our study, however, showed a significant association of work-related manual labor with arm lymphedema development. In our urban population of Detroit, Michigan, many manual laborers work in the automotive industry. This type of work may require lifting of heavy loads suddenly, rather than in a controlled, gradual increase as with exercise. Interventions to avoid sudden resumption of manual labor requiring lifting of heavy loads after breast cancer treatment may be beneficial in reducing the risk of lymphedema development. Citation Format: Lydia Choi, Hadeel Assad, Wei Chen, Tammy Demeere, Hyejeong Jang, Elizabeth Weisberg, Mary Ann Kosir. Arm lymphedema and socioeconomic factors in an urban cancer center [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 P4-11-22.

Abstract ES8-1: Options for reducing risk for lymphedema when ALND/regional nodal XRT are needed

Abstract Upper extremity lymphedema following axillary lymph node harvest or radiation therapy, can be extremely debilitating and symptomatic in breast cancer patients, and significantly reduces quality of life. In recent years, surgical procedures to reduce the development and progression of lymphedema have become more prevalent. These surgical procedures carry the aim of restoring lymphatic flow in the extremity following disruption of native channels. The most common procedures include vascularized lymph node transfer (VLNT) to the axilla, and lymphaticovenous bypass (LV bypass). The goal of both procedures is to restore flow, and reduce symptoms (infections, cellulitis, and reduced range of motion). VLNT involves harvest and transfer of autologous lymph node packets from a separate area of the body (most frequently the groin or supraclavicular region), and placement into the involved axilla, followed by microsurgical revascularization of the lymph nodes. Through cell signaling, this allows development of new lymphatic channel pathways, and resumption of drainage. LV bypass involves localized microsurgical anastomosis of lymphatic channels in the downstream affected extremity, directly to superficial veins in their vicinity. This allows lymphatic channels, proximal to the site of obstruction, to still drain their collected lymphatic fluid, directly into the systemic venous circulation in the extremity. In most cases, multiple LV bypass anastomoses are performed, to enhance lymphatic outflow. Due to the safety and efficacy of both procedures, they continue to be incorporated more frequently and routinely as part of breast reconstruction treatment plans. Citation Format: H Sbitany. Options for reducing risk for lymphedema when ALND/regional nodal XRT are needed [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 ES8-1.

Abstract OT1-04-01: ATNEC: A multi-centre, randomised trial investigating whether axillary treatment can be avoided in T1-3N1M0 breast cancer patients with no residual cancer in the lymph glands after neoadjuvant chemotherapy (clinicaltrials.gov: nct04109079)

Abstract Background: For patients who are node positive to start at presentation and are found to have a complete nodal tumour response (ypN0) post neoadjuvant chemotherapy (NACT), we do not yet know whether local axillary therapy can be modified based on the response to NACT. ATNEC randomised trial specifically address axillary management following NACT in patients with proven axillary node metastases. Methods: Design: ATNEC is a phase III, randomised (1:1), multi-centre trial, with embedded economic evaluation. Patients with proven axillary node metastases on needle biopsy receive NACT followed by sentinel node biopsy (SNB). If the sentinel nodes have converted to benign (ypN0), ATNEC randomly assigns patients to axillary treatment (nodal radiotherapy or axillary nodal clearance) vs. no axillary treatment (without further surgery). Aims: To assess whether, omitting further axillary treatment (ALND and ART) for patients with early stage breast cancer and axillary nodal metastases on needle biopsy - who after NACT have no residual nodal disease on SNB - is non-inferior to axillary treatment in terms of disease free survival, and reduces the risk of lymphoedema at 5 years. Stratification: Institution, type of surgery (breast conserving surgery [BCS] vs mastectomy), receptor status (triple negative vs HER2 positive vs ER status positive and/or PR status positive and HER2 negative). Inclusion criteria:. • Age ≥ 18. • Male or female. • T1-3N1M0 breast cancer at diagnosis (pre-NACT). • FNA or core biopsy confirmed axillary nodal metastases at presentation. • ER and HER2 status evaluated on primary tumour. • Received standard NACT as per local guidelines. • Imaging assessment of the axilla at completion of NACT. • Dual tracer SNB after NACT and at least 3 nodes removed (sentinel nodes and marked node). o If a single tracer is used, the patient is eligible if the involved node is marked before NACT and at least 3 nodes removed (including the marked node). o If axillary node sampling is performed following failed localisation of sentinel nodes, patient is eligible if at least 3 nodes removed (including the marked node). o If node is not marked, or marked node is not removed, patient is eligible if the histology report shows evidence of down-staging with complete pathological response in at least one node and at least 3 nodes removed. • No evidence of nodal metastases post NACT (ypN0). Exclusion criteria:. • Bilateral invasive breast cancer. • SNB prior to NACT. • Previous ipsilateral axillary nodal surgery. • Previous cancer within last 5 years or concomitant malignancy. Radiotherapy Quality Assurance: ATNEC has in-built radiotherapy QA programme that is coordinated by National Radiotherapy Trials QA (RTTQA) group. Target accrual: 1900 Number of sites: 100 Trial Status: Recruiting. Trial is open to new sites. Disclaimer: This study is funded by the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme (Reference - HTA NIHR128311). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. Citation Format: Amit Goyal, Sophie Cramp, Andrea Marshall, Duncan Wheatley, Natalie Hammonds, Shama Puri, Tara Homer, Luke Vale, Roeum Butt, Romaana Mir, Janice Rose, Helen Teresa Edwards, Samreen Ahmed, Abeer Shaaban, Beatrix Elsberger, Julie Bruce, Sophie Gasson, Valerie Speirs, Jacqui Shaw, Helen Higgins, Janet Dunn. ATNEC: A multi-centre, randomised trial investigating whether axillary treatment can be avoided in T1-3N1M0 breast cancer patients with no residual cancer in the lymph glands after neoadjuvant chemotherapy (clinicaltrials.gov: nct04109079) [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 OT1-04-01.

Jejunal Mesenteric Vascularized Lymph Node Transplantation for Lymphedema: Outcomes and Technical Modifications.

The jejunal mesentery supplied by the superior mesenteric vascular tree has emerged as a viable site for vascularized lymph node transplantation. Among other benefits, it has the advantage of avoidance of the risk of donor-site lymphedema. This article reports the technique and outcomes of a novel approach to jejunal mesenteric vascularized lymph node transplantation with flap harvest from the mesenteric root to reduce the risk of small bowel ischemic complications. A consecutive series of patients that underwent jejunal mesenteric vascularized lymph node transplantation to treat upper extremity lymphedema were included. Preoperative and postoperative measurements were taken at fixed intervals using standardized techniques including Perometer volumetry, LDex bioimpedance spectroscopy, the Lymphedema Life Impact Scale, and the Quick Disabilities of the Arm, Shoulder and Hand tool. Demographic, treatment, and outcomes data were collected, and descriptive statistics were used. There were 25 patients included, all of whom had maximized their conservative therapy before undergoing surgery. At 12 months postoperatively reduction in limb volume difference was 36.7 percent (p < 0.001), reduction in LDex score was 41.4 percent (p = 0.0015), and reductions in the Lymphedema Life Impact Scale and Quick Disabilities of the Arm, Shoulder and Hand scores were 55.7 percent (p = 0.0019) and 47.5 percent (p = 0.027), respectively. In 11 patients, there was a history of cellulitis (multiple episodes in eight), and at up to 24 months' follow-up postoperatively there were no episodes reported (p < 0.001). Upper extremity lymphedema can be effectively treated surgically using the jejunal mesenteric vascularized lymph node transplantation, resulting in reduced limb volume and extracellular fluid, and improved patient-reported limb function and outcomes measures compared with optimized conservative therapy alone. Therapeutic, IV.

National Outcomes of Prophylactic Lymphovenous Bypass during Axillary Lymph Node Dissection.

Breast cancer treatment, including axillary lymph node excision, radiation, and chemotherapy, can cause upper extremity lymphedema, increasing morbidity and health care costs. Institutions increasingly perform prophylactic lymphovenous bypass (LVB) at the time of axillary lymph node dissection (ALND) to reduce the risk of lymphedema but reports of complications are lacking. We examine records from the American College of Surgeons (ACS) National Surgery Quality Improvement Program (NSQIP) database to examine the safety of these procedures. Procedures involving ALND from 2013 to 2019 were extracted from the NSQIP database. Patients who simultaneously underwent procedures with the Current Procedural Terminology (CPT) codes 38999 (other procedures of the lymphatic system), 35201 (repair of blood vessel), or 38308 (lymphangiotomy) formed the prophylactic LVB group. Patients in the LVB and non-LVB groups were compared for differences in demographics and 30-day postoperative complications including unplanned reoperation, deep vein thrombosis (DVT), wound dehiscence, and surgical site infection. Subgroup analysis was performed, controlling for extent of breast surgery and reconstruction. Multivariate logistic regression was performed to identify predictors of reoperation. The ALND without LVB group contained 45,057 patients, and the ALND with LVB group contained 255 (0.6%). Overall, the LVB group was associated with increased operative time (288 vs. 147 minutes, p < 0.001) and length of stay (1.7 vs. 1.3 days, p < 0.001). In patients with concurrent mastectomy without immediate reconstruction, the LVB group had a higher rate of DVTs (3.0 vs. 0.2%, p = 0.009). Reoperation, wound infection, and dehiscence rates did not differ across subgroups. Multivariate logistic regression showed that LVB was not a predictor of reoperations. Prophylactic LVB at time of ALND is a generally safe and well-tolerated procedure and is not associated with increased reoperations or wound complications. Although only four patients in the LVB group had DVTs, this was a significantly higher rate than in the non-LVB group and warrants further investigation.