Risk Of Lymphedema Research Articles

Utilization of Forearm Crutches to Avoid Lymphedema After Breast Cancer Lymph Node Surgery: A Case Report

Background: Despite many patients with breast cancer being advised to limit upper extremity (UE) use, there is growing evidence that UE use is not associated with lymphedema. Subsequently, clinicians may be unsure of how to advise patients with a history of breast cancer who need assistive devices to ambulate. Study Design/Case Description: A 51-year-old woman who had recently undergone treatment for breast cancer sustained a knee injury requiring the use of crutches. Forearm crutches were used instead of axillary crutches to minimize the potential for irritation to the axillary lymphatic vessels and thus reduce the risk for lymphedema. L-Dex measures were used to monitor for lymphedema. Outcomes: L-Dex scores did not exceed the change of more than +7.1 to indicate the presence of lymphedema. Furthermore, there were no clinical signs or symptoms of lymphedema while using crutches and in the 7 months following. Discussion: Prolonged rigorous UE use by ambulating non-weight-bearing with forearm crutches within 1 to 2 months of treatment for breast cancer did not result in UE lymphedema. This case report reinforces the growing body of evidence that avoiding aggressive UE activity may not be necessary in those at low risk of lymphedema and informs assistive device prescription for patients with breast cancer.

Breast cancer‐related lymphoedema: Risk factors and prediction model

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. Predictive retrospective cohort study comparing women who developed lymphoedema in 2years of undergoing ALND with those who did not developed lymphoedema. 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. 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. 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. 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.

American Society of Breast Surgeons' Practice Patterns for Patients at Risk and Affected by Breast Cancer-Related Lymphedema.

In 2017, the American Society of Breast Surgeons (ASBrS) published expert panel recommendations for patients at risk for breast cancer-related lymphedema (BCRL) and those affected by BCRL. This study sought to determine BCRL practice patterns. A survey was sent to 2975 ASBrS members. Questions evaluated members' clinical practice type, practice duration, and familiarity with BCRL recommendations. Descriptive statistics, the chi-square test, and Fisher's exact test were used. Of the ASBrS members surveyed, 390 (13.1%) responded. Most of the breast surgeons (58.5%, 228/390) indicated unfamiliarity with recommendations. Nearly all respondents (98.7%, 385/390) educate at-risk patients. Most (60.2%, 234/389) instruct patients to avoid venipuncture, injection or blood pressure measurements in the at-risk arm, and 35.6% (138/388) recommend prophylactic compression sleeve use during air travel. Nearly all (97.7%, 380/389) encourage those at-risk to exercise, including resistance exercise (86.2%, 331/384). Most do not perform axillary reverse mapping (ARM) (67.9%, 264/389) or a lymphatic preventive healing approach (LYMPHA) (84.9%, 331/390). Most (76.1%, 296/389) screen at-risk patients for BCRL. The most frequently used screening tools include self-reported symptoms (81%, 255/315), circumferential tape measure (54%, 170/315) and bioimpedance spectroscopy (27.3%, 86/315). After a BCRL diagnosis, most (90%, 351/390) refer management to a lymphedema-certified physical therapist. For affected patients, nearly all encourage exercise (98.7%, 384/389). Many (49%, 191/390) refer affected patients for consideration of lymphovenous bypass or lymph node transfer. Most respondents were unfamiliar with the ASBrS expert panel recommendations for patients at risk for BCRL and those affected by BCRL. Opportunities exist to increase awareness of best practices and to acquire ARM and LYMPHA technical expertise.

Weight loss does not decrease risk of breast cancer-related arm lymphedema.

The goal of this study was to determine the relationship between postoperative weight change and breast cancer-related lymphedema (BCRL). In this cohort study, 1161 women underwent unilateral breast surgery for breast cancer from 2005 to 2020 and were prospectively screened for BCRL. Arm volume measurements were obtained via an optoelectronic perometer preoperatively, postoperatively, and in the follow-up setting every 6 to 12 months. Mean follow-up from preoperative baseline was 49.1 months. The main outcome was BCRL, defined as a relative volume change of the ipsilateral arm of ≥10% at least 3 months after surgery. A total of 92 patients (7.9%) developed BCRL. Net weight loss versus net weight gain from baseline to last follow-up was not protective against developing BCRL (hazard ratio, 1.38; 95% confidence interval, 0.89-2.13; P = .152). Although weight loss may be recommended as part of an individualized lifestyle management program for overall health, weight loss alone may not decrease the risk of developing BCRL.

THE EFFICACY OF PHYSIOTHERAPY RECOVERY AFTER A MODIFIED RADICAL MASTECTOMY

Breast cancer is the most common disease in females and the major cause of mortality and morbidity. In reality, 1.67 million new cases of breast cancer are diagnosed around the world, with 458,000 deaths per year. Approximately 89 percent of breast cancer survivors live for a minimum of five years after treatment, but adverse effects can last for months or years after surgery. The most common side effects of the upper limb are pain and joint dysfunction, which is described as having a prevalence range of 12 percent to 51 percent for pain and 1.5 percent to 50 percent for joint dysfunction.(1) The mainstay in primary breast cancer care is surgery.(2) To assess the impact of an early recovery program on shoulder mobility, functional ability, postoperative complications such as seroma, hematoma, and wound infection in patients who had undergone a modified radical mastectomy (MRM)and to assess the impact of variables in clinical practice (e.g., age, education, BMI, previous shoulder problems, number of dissected axillary lymph nodes and metastatic lymph nodes, use of postoperative radiotherapy (RT) and chemotherapy on shoulder mobility, functional ability, and lymphedema development), and lymphedema.(3) Any of these symptoms can result in permanent arm dysfunction. Shoulder exercises are widely prescribed to minimize the impairment of mobility and strength as well as to prevent lymphedema. A variety in clinical services has been established which help mostly in improvement of shoulder range of motion while also reducing the risk of secondary lymphedema. This is the case of a 32-year-old female, resident of Dastur Nagar, Amravati. Housewife by occupation. She has swelling in her right breast so she visited a private hospital in Amravati. There she detected a lump in her right breast and the doctor recommended further treatment to visit AVBRH Hospital, Sawangi Meghe, and Wardha. She underwent a modified radical mastectomy. Patients that have had a mastectomy are always at the possibility of experiencing shoulder pain and adhesive capsulitis and require preventative measures.

Loco-regional therapy and the risk of breast cancer-related lymphedema: a systematic review and meta-analysis.

This meta-analysis was designed to assess the association between two loco-regional therapies, regionalnodal irradiation (RNI) and axillary lymph node dissection (ALND), and breast cancer-related lymphoedema (BCRL). We searched PubMed, Science Direct, Embase, and BMJ databases for clinical studies published between January 1, 2010 and January 1, 2020, which assessed risk factors and incidence/prevalence of BCRL. Two investigators independently selected articles to extract relative data and calculate corresponding exact binomial 95% confidence intervals (CIs). In total, 93 articles were reviewed, from which 19 studies were selected. The extracted data were pooled using a random-effects mixed model. The incidence of lymphedema in the selected studies ranged from 3% to 36.7%, with a pooled incidence of 14.29% (95% CI 13.79-14.79). The summary odds ratio/risk ratio (OR/RR) of ALND vs. no-ALND was 3.67 (95% CI 2.25-5.98) with a heterogeneity (I2) of 81% (P < 0.00001). After excluding the studies with an abnormally high risk of lymphedema from self-reporting, the summary hazard ratio (HR) was 2.99 (95% CI 2.44-3.66) with no heterogeneity (I2 = 0%, P = 0.83). The summary OR/RR of patients with vs. without radiotherapy (RT) was 1.82 (95% CI 0.92-3.59), but the RR of RT to breast/chest vs. both axillary and supraclavicular areas was 2.66 (95% CI 0.73-9.70). Regional nodal irradiation has a significantly higher risk for developing lymphedema than irradiation of the breast/chest wall. Axillary dissection and axillary RT have a similar risk for early-onset of breast cancer-related lymphoedema, although the risk trends higher for axillary dissection.

Paclitaxel versus docetaxel-based neoadjuvant chemotherapy and risk of lymphedema in breast cancer patients.

e12620 Background: Neoadjuvant chemotherapy (NAC) is commonly utilized in women with locally advanced breast cancer, usually followed by surgery and radiation therapy (RT). Many studies aimed to address the risk factors contributing to a higher incidence of lymphedema in patients with breast cancer. Our group previously reported the extent of surgery increases the risk of lymphedema. Adjuvant chemotherapy with taxane-based regimens are associated with an increased risk of lymphedema likely due an increase in interstitial extracellular fluid volume therefore resulting in fluid retention. This study aims to directly compare and characterize the risk of lymphedema in patients receiving paclitaxel versus docetaxel-based NAC. Methods: This is a retrospective study approved by our institutional review board. The study included women with breast cancer treated consecutively at our institution with taxane-based NAC followed by surgery and RT from 2006 to 2018. Patients and tumor characteristics including age, race, body mass index (BMI), clinical stage, hormone receptor, HER2 status, type of surgery, RT techniques, and type of NAC (Paclitaxel versus Docetaxel), and its association to risk of lymphedema were analyzed using univariable and multivariable binary logic regression tests. Lymphedema was assessed before RT and at follow up visits, and was identified by &gt;2.0-cm increase in arm circumference, or &gt;10% increase in limb volume, or new self-reported lymphedema symptoms. Results: A total of 263 patients treated with either paclitaxel or docetaxel-based NAC were identified and analyzed. At a median follow up of 28.4 months (range 3.5-158.7 months). 26.2% (69/263) of patients developed lymphedema. On a multivariable analysis, patients who underwent axillary lymph node dissection (ALND) had a significantly higher rate of lymphedema (42.6%) compared to those who had only a sentinel lymph node biopsy (SLNB, 10.5%, p&lt;0.05). Regardless of the type of surgery, there was no significant difference in rates of lymphedema between patients who received paclitaxel versus docetaxel-based NAC (28.7% vs 21.3%). However, among high-risk patients who underwent mastectomy with ALND, NAC with Paclitaxel was associated with a significantly higher rate of lymphedema compared to docetaxel (56.8% vs 22.7%, RR 2.50, p&lt;0.05). Conclusions: This represents one of the largest studies examining the impact of taxane-based NAC on the risk of lymphedema in women with breast cancer. In this study, paclitaxel-based NAC was associated with a significantly higher risk of lymphedema in women who underwent mastectomy and ALND compared to docetaxel based chemotherapy. A larger, balanced, prospective study is warranted to verify this previously unidentified lymphedema risk from paclitaxel and guide individualized NAC decision.

Axillary management in T1-3N1M0 breast cancer patients with needle biopsy proven nodal metastases at presentation after neoadjuvant chemotherapy (ATNEC).

TPS600 Background: Neoadjuvant chemotherapy (NACT) results in eradication of cancer in the axillary nodes in 40% to 70% of patients. This raises questions about the benefit of further axillary treatment in those patients with no evidence of residual nodal disease (ypN0) after NACT. Methods: Design: ATNEC is a phase 3, randomised (1:1), multi-centre trial, with embedded economic evaluation, comparing standard axillary treatment (axillary lymph node dissection [ALND] or axillary radiotherapy [ART]) with no further axillary treatment in T1-3N1M0 breast cancer patients with needle biopsy proven axillary nodal metastases, who after NACT have no residual nodal disease (ypN0) on dual tracer sentinel node biopsy (SNB) and removal of at least 3 nodes (sentinel nodes and marked involved node). Stratification: Institution, type of surgery (breast conserving surgery vs mastectomy), receptor status (triple negative vs HER2 positive vs ER positive and/or PR positive and HER2 negative). Inclusion criteria are: 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, ultrasound of the axilla at completion of NACT, dual tracer SNB after NACT and at least 3 nodes removed (sentinel nodes and marked node), no evidence of nodal metastases post NACT (ypN0). Exclusion criteria are: bilateral invasive breast cancer, SNB prior to NACT, marked node not removed except where at least one node removed shows evidence of down-staging with complete pathological response e.g. fibrosis/scarring and at least 3 nodes removed, previous ipsilateral axillary surgery, previous cancer within last 5 years or concomitant malignancy except basal or squamous cell carcinoma of the skin, in situ carcinoma of the cervix, in situ or stage 1 melanoma, contra- or ipsilateral in situ breast cancer. 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 (ypN0) - is non-inferior to axillary treatment in terms of disease free survival, and reduces the risk of lymphoedema at 5 years. Statistical methods: All analyses will be carried out on an intention-to-treat basis to preserve randomisation, avoid bias from exclusions and preserve statistical power. Radiotherapy quality assurance: Study has in-built radiotherapy QA programme that will be co-ordinated by National Radiotherapy Trials QA (RTTQA) group. Target accrual: 1900. Trial status: Recruiting. Number of sites: 100. Clinical trial information: NCT04109079.

Recognizing genital lymphoedema after penile cancer

AbstractLymphadenectomy for penile cancer treatment increases the risk of genital lymphoedema. There is very little acknowledgment of the risk of genital lymphoedema after penile cancer or its treatment in current literature. Genital lymphoedema is most responsive to treatment in the early stages before irreversible skin changes occur; therefore, early identification would benefit patients. A urology clinic‐based study found an assumption among health care professionals that in patients with a broad range of genital cancers, post‐operative acute genital oedema would resolve on its own, meaning vigilance for chronic lymphoedema was low. It is unclear whether vigilance for lymphoedema is any higher in specialist centres treating penile cancer. This article describes some of the challenges of recognizing genital lymphoedema in an uro‐oncology caseload and specifically in relation to penile cancer. An example case report of penile cancer‐related lymphoedema is described and puts this within the context of two relevant studies, one in a single uro‐oncology centre and the other a wider international education need study of health professionals who manage genital lymphoedema. For patients identified at particular risk, adding genital lymphoedema to the list of possible consequences of treatment could mean timely access to advice and treatment, resulting in better health outcomes. Making health professionals aware of the availability of information and education resources regarding rarely encountered conditions can be challenging. Lymphoedema specialists in collaboration with urology specialist nurses and physicians, and pelvic floor specialists have developed support and education resources to meet the identified needs. These included improved assessment documentation, accredited e‐learning, updated course materials for specialists, a series of international webinars and a set of six brief, free‐to‐view videos, hosted on the website of a recognized international lymphoedema charity.

GATA2 participates in the recanalization of lymphatic vessels after surgical lymph node extirpation.

Lymphatic recanalization failure after lymphadenectomy constitutes a major risk of lymphedema in cancer surgery. It has been reported that GATA2, a zinc finger transcription factor, is expressed in lymphatic endothelial cells and is involved in the development of fetal lymphatic vessels. GATA3, another member of the GATA family of transcription factors, is required for the differentiation of lymphoid tissue inducer (LTi) cells and is essential for lymph node formation. However, how GATA2 and GATA3 function in recanalization after the surgical extirpation of lymphatic vessels has not been elucidated. Employing a new model of lymphatic recanalization, we examined the lymphatic reconnection process in Gata2 heterozygous deficient (Gata2+/- ) and Gata3 heterozygous deficient (Gata3+/- ) mice. We found that lymphatic recanalization was significantly impaired in Gata2+/- mice, while Gata3+/- mice rarely showed such abnormalities. Notably, the perturbed lymphatic recanalization in the Gata2+/- mice was partially restored by crossing with the Gata3+/- mice. Our results demonstrate for the first time that GATA2 participates in the regeneration of damaged lymphatic vessels and the unexpected suppressive activity of GATA3 against lymphatic recanalization processes.

The Lymph-Sparing Quotient: A Retrospective Risk Analysis on Extremity Radiation for Soft Tissue Sarcoma Treatment.

Simple SummarySoft tissue sarcomas, a heterogenous group of tumors with a mesenchymal origin, are mostly located in the extremities and are commonly treated with surgery and radiotherapy. Using opportunities of reducing long-term therapy-related side effects in soft tissue sarcoma treatment is an important task for all physicians involved in soft tissue sarcoma treatment. The extent of lymph-sparing volume in adjuvant radiation therapy of extremity soft tissue sarcoma as a risk factor for lymphedema was analyzed in this study. Patients with a low lymph-sparing volume showed an increased risk of lymphedema in this retrospective study. Maximizing the potential oncologically justifiable lymph-sparing volume should be considered to reduce the risk of high-grade lymphedema when applying RT to extremities.Radiation therapy (RT) for extremity soft tissue sarcoma is associated with lymphedema risk. In this study, we analyzed the influence of lymph-sparing volume on the lymphedema occurrence in patients who received adjuvant extremity RT. The lymph-sparing quotient (LSQ) was calculated by dividing the lymph-sparing volume by the total extremity volume with double weightingfor the narrowest lymph-sparing region. A total of 34 patients were enrolled in this analysis. The median applied total radiation dose was 66.3 Gy in 36 fractions. Acute lymphedema appeared in 12 patients (35%). Most of them (n = 8) were lymphedema grade 1 and five patients had grade 2 to 3 lymphedema. Chronic lymphedema appeared in 22 patients (65%). 17 of these patients had at least a grade 2 lymphedema. In 13 of 14 patients with an LSQ ≤ 0.2 and 11 of 20 patients with an LSQ > 0.2, an acute or chronic lymphedema ≥ grade 2 was observed. A Kaplan–Meier Analysis of the two groups with the endpoint of a two-year lymph edema-free survival (=2-YLEFS) was estimated with an univariate, significant result (2-YLEFS LSQ ≤ 0.2 vs. LSQ > 0.2: 0% vs. 39%; p = 0.006; hazard ratio LSQ ≤ 0.2 vs. > 0.2 2-YLEFS 2.822 (p = 0.013); 95% confidence interval (CI): 1.24–6.42). Maximizing the potential oncologically-justifiable lymph-sparing volume should be considered to reduce the risk of high-grade lymphedema when applying RT to extremities.

Study on the Design and Optimization of a Portable Monitoring and Auxiliary Treatment Device for Upper Extremity Lymphedema-Focus on the Rehabilitation Function of the Device.

Female patients suffer from the risk of upper limb lymphedema after breast cancer removal surgery. At present, the detection and the adjuvant treatment of this disease are not convenient enough, leading to delay of the disease and increase in the burden of patients. This paper presents a portable monitoring and treatment device for upper extremity lymphedema, enabling patients to monitor the symptoms of upper limb lymphedema and auxiliary rehabilitation. This design utilizes the arm circumference measurement and contrast method to realize symptom monitoring. The device realizes auxiliary rehabilitation using the regional pressure method to imitate traditional manual lymphatic drainage technology. According to the MRI images of volunteers’ upper limbs, the upper arm and forearm’s finite element models are reconstructed in ANSYS. The static simulation experiment is completed. The working mode and parameter design of each rehabilitation module of the device are obtained. The experimental results show that the integrated design principle of monitoring and treatment proposed in this paper has good feasibility, has auxiliary rehabilitation effect, and meets the principle of human comfort. The device can help patients find lymphedema in time and implement auxiliary treatment, which can effectively avoid the further deterioration of lymphedema.

Sentinel lymph node in cervical cancer: time to move forward.

In early-stage cervical cancer, lymph node status is of paramount importance to determine the best therapeutic strategy and is one of the most important prognostic factors of survival. According to main international guidelines, pelvic full lymphadenectomy is recommended for lymph node staging. Sentinel lymph node (SLN) biopsy is an accurate method for the assessment of lymph nodal involvement and has been suggested instead of systematic pelvic lymph node dissection (PLND). The SLN technique requires a learning-curve to be well performed. Combined detection with technetium-99 and blue dye has been widely used but the recent introduction of indocyanine green (ICG) is of growing interest since it could improve SLN detection. SLN biopsy offers a more accurate anatomical staging by finding potential metastatic nodes outside of usual lymphadenectomy areas. SLN biopsy improves the diagnostic value of lymph node staging with ultrastaging and detection of low-volume nodal metastases [isolated tumor cells (ITCs) and micrometastases]. Appropriate selection of patient and minimal training combined with some simple rules may guarantee a low false negative rate. Several studies have shown that SLN mapping in these patients is feasible, with excellent detection rates and sensitivity. Less-radical lymph node dissection decreases the associated morbidity of PLND, especially the risk of lower-limb lymphoedema, which severely affects patient quality of life. Some points are still subject to debate such as the low accuracy of intraoperative SLN status assessment by frozen section and the impact of micrometastasis on prognosis. Although international guidelines consider SLN biopsy as an alternative to PLND, SLN biopsy alone is not the gold-standard yet due to lack of prospective evidence on long-term oncological safety. The 3 ongoing prospective trials SENTIX, PHENIX and SENTICOL III will most probably give an answer to these issues.

A historical literature review on the role of posterior axillary boost field in the axillary lymph node coverage and development of lymphedema following regional nodal irradiation in breast cancer.

To elucidate whether (1) a posterior axillary boost (PAB) field is an optimal method to target axillary lymph nodes (LNs); and (2) the addition of a PAB increases the incidence of lymphedema, a systematic review was undertaken. A literature search was performed in the PubMed database. A total of 16 studies were evaluated. There were no randomized studies. Seven articles have investigated dosimetric aspects of a PAB. The remaining 9 articles have determined the effect of a PAB field on the risk of lymphedema. Only 2 of 9 articles have prospectively reported the impact of a PAB on the risk of lymphedema development. There are conflicting reports on the necessity of a PAB. The PAB field provides a good coverage of level I/II axillary LNs because these nodes are usually at a greater depth. The main concern regarding a PAB is that it produces a hot spot in the anterior region of the axilla. Planning studies optimized a traditional PAB field. Prospective studies and the vast majority of retrospective studies have reported the use of a PAB field does not result in increasing the risk of lymphedema development over supraclavicular-only field. The controversies in the incidence of lymphedema suggest that field design may be more important than field arrangement. A key factor regarding the use of a PAB is the depth of axillary LNs. The PAB field should not be used unless there is an absolute indication for its application. Clinicians should weigh lymphedema risk in individual patients against the limited benefit of a PAB, in particular after axillary dissection. The testing of the inclusion of upper arm lymphatics in the regional LN irradiation target volume, and universal methodology measuring lymphedema are all areas for possible future studies.

Development and validation of a nomogram to predict the risk of breast cancer-related lymphedema among Chinese breast cancer survivors.

Breast cancer-related lymphedema (BCRL) is a major long-term complication for post-surgery breast cancer survivors. Although several risk factors have been identified, lifestyle characteristics have been neglected in previous studies. The aim of this study was to develop and validate a nomogram for estimating this population's risk of developing lymphedema, taking into consideration their demographic, clinical, and personal lifestyle behaviors. In a cross-sectional study, we collected data from 775 post-operative breast cancer survivors who had attended a follow-up session in the recent 10 years (primary cohort). Lymphedema was assessed using the Norman telephone questionnaire, self-reported by patients. Multiple logistic regression was used to identify risk factors for lymphedema, including demographic, clinical, and lifestyle-related factors. A nomogram was constructed based on those factors and was validated using a separate group of 314 breast cancer patients (validation cohort). The factors independently associated with lymphedema were higher body mass index (BMI), modified radical mastectomy (MRM), postsurgical infection, chemotherapy, radiotherapy, exercise of the affected arm, and the active participation in physical activity (P<0.05). The area under the curve (AUC) values of the primary and the validation cohorts were 0.721 (95% confidence interval: 0.685-0.756) and 0.702 (95% confidence interval: 0.646-0.759), respectively. BCRL risk factors include MRM, radiotherapy, chemotherapy, and higher BMI, while the active physical activity behavior of patients appears to be a factor against lymphedema. The nomogram incorporating the patients' clinical and lifestyle factors might be useful for predicting lymphedema in breast cancer survivors.

Lymphaticovenular Anastomosis in Breast Cancer Treatment-Related Lymphedema: A Short-Term Clinicopathological Analysis from Indonesia.

Locally advanced breast cancer is commonly found in Indonesia. In this group of patients, aggressive treatment such as axillary lymph nodes dissection (ALND) with or without regional nodal irradiation (RNI) will increase the risk of breast cancer treatment-related lymphedema (BCRL) in our patients. Lymphaticovenular anastomosis (LVA) has been established as a minimally invasive approach in lymphedema surgery. In this study, we report our first experience of LVAs in BCRL patients. This was a cross-sectional study taken from breast cancer patients receiving ALND with or without RNI. From December 2018 until June 2020, we collected and described general patient information, tumor characteristics, diagnostic methods, and the outcome of LVA. Postoperative subjective symptoms scores (lymphedema quality-of-life score [LeQOLiS]) and lymphedematous volume (upper extremity lymphedema [UEL] index) were compared with preoperative ones. Seventy patients experienced BCRL with the mean age of 54.8 (9.4) years and mean body mass index of 28.1 (4.5). ALND was performed in 66 (97.1%) cases and RNI was given in 58 (82.9%) patients. Thirty-one (44.3%) patients were in the International Society of Lymphology stage 1, 24 (34.3%) in stage 2A, and 15 (21.4%) in stage 2B. The mean lymphatic vessel diameter was 0.5 (0.26) mm and 0.80 (0.54) mm for the vein. Lymphosclerosis severity was 7 (4%) in S0 type, 129 (74.1%) in S1 type, 37 (21.3%) in S2 type, and 1 (0.6%) in S3 type. In histopathology examination, S1 types were in lower grade injury, while S2 and S3 types were in the higher grade. Seven (53.8%) cases of S2 type showed severe fibrosis from trichrome staining. Postoperative LeQOLiSs were significantly lower than preoperative ones (5.6 ± 2.4 vs. 3.7 ± 2.6; p = 0.000). With the mean follow-up of 7.4 (3.7) months, the overall UEL index reduction was 9.2%; mean -11 (16.8). Postoperative UEL index was significantly lower than preoperative ones (117.7 ± 26.5 vs. 106.9 ± 18.5; p = 0.000). No complications were observed during this period. LVA reduced the subjective symptoms and UEL index in BCRL cases. Future studies using updated imaging technologies of the lymphatic system and longer follow-up time are needed to confirm our results.

Expanding the Horizon: Single-port Robotic Vascularized Omentum Lymphatic Transplant.

Summary:Vascularized omentum lymphatic transplant is frequently used for the treatment of lymphedema due to demonstrated efficacy, a reduced complication profile, and, in particular, negligible risk of donor site lymphedema. Historically harvested by open laparotomy, more recent techniques involve laparoscopic omental harvest. Although effective and reproducible, laparoscopy may be limited by reduced visualization, minimal tactile feedback, multiple port sites, and imprecise instrumentation. Therefore, we employed the da Vinci Single-Port (SP) surgical robot system for vascularized omentum lymphatic transplant. A 52-year-old man with a 3-year history of progressive left lower extremity swelling and lymphoscintigraphy and magnetic resonance lymphangiogram consistent with lymphedema of unknown etiology underwent vascularized omentum lymphatic transplant to the left groin. A 2.5-cm infraumbilical incision was used for placement of the primary trocar, through which the camera and operating instruments were passed. Following robotic harvest, the omental lymph node flap was transferred to the left groin for microsurgical anastomosis. The procedure was uneventful, and the patient was discharged on postoperative day 1. At 6 weeks, there were no complications. Here, we show for the first time the safety and feasibility of robotic omental lymph node flap harvest for extremity lymphedema using the da Vinci Single-Port robotic system. The benefits of this technology include a minimally-invasive approach that allows for flap dissection and removal through a single 2.5-cm incision. Further investigation is necessary to characterize the indications and limitations of this technique in plastic surgery.

Abstract PS1-12: Factors associated with chronic breast lymphedema after adjuvant radiation in women undergoing breast conservation therapy

Abstract Purpose/Objective(s):Unlike temporary breast edema caused by post-lumpectomy radiation therapy (RT), the edema that persists beyond one year is not well defined and difficult to treat. The aim of this study is to define the incidence and risk factors for the development of chronic breast lymphedema in women undergoing lumpectomy with RT at a large metropolitan cancer center. Materials/Methods:A retrospective chart review was performed on all patients who underwent lumpectomy from 2014 to 2018. Women who did not undergo RT at our institution and those with stage IV disease were excluded from the analysis. Patient demographics, comorbidities, operative data, RT data and postoperative complications were obtained. Chronic breast lymphedema (CBL) was defined as edema that persisted beyond one year post completion of radiation therapy. Breast volumes were determined by contoured breast volumes or, if unavailable, estimated by the 95% isodose volumes from the RT treatment planning system. Using a density curve, the distribution of breast volumes was plotted for patients with and patients without CBL. Univariate analysis was used to evaluate factors associated with CBL. Multivariate regression analysis was used to evaluate factors associated with the risk of CBL while accounting for potential confounding variables as defined by the univariate analysis. Results:A total of 1173 patients were included for analysis. Seventy-four (6.3%) patients developed breast lymphedema beyond one year. For the entire cohort, mean age was 63 years old (SD=11.17), mean BMI was 31.15 kg/m2 (SD=7.17), mean breast volume was 1198.54 cm3 (SD=645.82 cm3), mean total radiation was 59.18 Gy (SD=16.76), and 139 (11.8%) patients underwent ALND. Compared to the cohort that did not develop CBL (n=1099), the CBL cohort (n=74) had a higher median BMI (33.23 kg/m2 vs. 29.81 kg/m2, P&amp;lt;0.001), higher percentage of African Americans (56.8% vs. 37.9%, P=0.004), larger median breast volume (1502.33 cm3 vs. 1083.59 cm3, P&amp;lt;0.001), higher percentage that underwent ALND (23% vs. 11.1%, P=0.005), and larger median size of lumpectomy specimen (128.00 cm3 vs. 94.57 cm3, P=0.002). When accounting for potential confounding variables, multivariate regression analysis revealed when breast volume was evaluated as a continuous variable, for every 1 cm3 increase in breast volume, the risk of breast lymphedema increases by 0.1% (OR=1.001, P&amp;lt;0.001). When breast volume was analyzed as a categorical variable using 1300 cm3 as the optimal cutoff (based on density curve evaluations), patients whose breast volume was greater than 1300 cm3 had nearly 3 times the risk of developing CBL (OR=2.976, P&amp;lt;0.001) compared to those with less than 1300 cm3 breast volume. The multivariate regression also demonstrated that CBL was associated with total radiation dose (OR=1.02, P=0.015) and African American race (OR=1.705, P=0.037). Conclusion:Chronic breast lymphedema presents a clinical concern for women undergoing lumpectomy with postoperative radiation, particularly in women with larger breasts. Further studies should focus on preventative strategies, as well as the psychosocial and economic impact of this morbidity. Citation Format: Sanjay Rama, Cara Canella, Jenna Luker, Kelley Park, Renee Barry, Saheli Ghosh, Simeng Zhu, Yalei Chen, Jessica Bensenhaver, Eleanor Walker, Kenneth Levin, Dunya Atisha, Maristella Evangelista. Factors associated with chronic breast lymphedema after adjuvant radiation in women undergoing breast conservation therapy [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS1-12.

Abstract SP023: State of the art treatment for neoadjuvant/adjuvant triple negative breast cancer

Abstract Systemic therapy for triple negative breast cancer (TNBC) is currently limited to chemotherapy, with the major questions being the nature and timing of the chemotherapy and optimizing locoregional management of the primary tumor. While TNBC carries the worst prognosis of the clinical subtypes, this prognosis has improved with modern treatment approaches (Cossetti RJ, JCO 2015), and there are subsets within TNBC that have excellent outcomes. Giving the chemotherapy neoadjuvantly has real clinical value. Cytoreduction can facilitate breast conserving surgery (BCS); 42-53% of patients considered ineligible convert to BCS-eligible after chemotherapy (Golshan M et al, Ann Surg 2015 and JAMA Surg 2020). A negative sentinel lymphadenectomy post-chemotherapy is reliable if dual tracer is used and at least three sentinel nodes are retrieved (Boughey J, JAMA 2013), and a high proportion of node-positive breast cancer can be converted to node-negative, allowing omission of axillary dissection and minimizing risk of lymphedema (Pilewskie M, Morrow M, JAMA Oncol 2017). Two ongoing trials in patients with up-front node-positive disease are examining omitting radiation in those converting to node-negative (NSABP B-51, NCT01872975), and axillary radiation instead of dissection in those that remain pathologically node-positive (A011202, NCT01901094). Pathologic complete response (pCR) to chemotherapy across all subtypes of breast cancer carries a markedly better prognosis compared with residual disease. In CALGB 40603, at over 5 years’ followup, 86% of pCR versus 57% of residual disease patients were event-free (Sikov W, SABCS 2019). CREATE-X enrolled approximately 900 patients with HER2-negative tumors and residual disease after chemotherapy, one-third TNBC, who were randomized to the addition of capecitabine versus standard adjuvant treatment. At 3.5 years’ followup, there was a benefit to adding capecitabine, driven by the TNBC subset in whom there was an absolute 14% difference in disease-free and 8.5% difference in overall survival (Masuda, NEJM 2017). For these two reasons (surgical optimization and risk stratification with treatment decisions driven by residual disease status), in TNBC patients appropriate for chemotherapy neoadjuvant timing is preferred. The nature of the regimens has evolved also during the modern era. The key improvements in chemotherapy includes the addition of taxanes to anthracyclines (Hayes DF, NEJM 2007), the use of dose dense schedules made possible through the development of growth factors (Citron M, JCO 2003), and efforts to minimize anthracycline use. The ABC Trials were a joint analysis of several trials examining anthracycline/taxane-based regimens (TAC or dose-dense AC-T) versus a similar duration (six cycles) of docetaxel plus cyclophosphamide (TC). While underpowered for subset analyses, in the 1300 TNBC patient cohort, anthracycline/taxane regimens outperformed TC, although the absolute benefits were modest in node-negative (2.5%) compared with node-positive (&amp;gt;10%) (Blum J, JCO 2017). For this reason, the preferred regimen in TNBC remains anthracycline/taxane-based. A separate consideration is the incorporation of platinums. Several trials have demonstrated that adding carboplatin significantly increases the pCR rate. However the impact on relapse has been mixed (in underpowered trials); it is reasonable to add in high clinical risk where surgical optimization is desired but is not considered a standard addition to reduce risk of recurrence. Future advances include further surgical and radiation optimization, the potential for using clinical and biomarker analyses to identify low risk TNBC that need no chemotherapy at all, and the incorporation of immune checkpoint inhibitors, which in two neoadjuvant trials have demonstrated significantly increased pCR. Citation Format: LA Carey. State of the art treatment for neoadjuvant/adjuvant triple negative breast cancer [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr SP023.

Prevalence and predictors of breast cancer-related arm lymphedema over a 10-year period in postoperative breast cancer patients: A cross-sectional study.

Breast cancer (BC) survivors have a lifelong risk of developing lymphedema. This study investigated the prevalence of BC-related arm lymphedema among Chinese BC survivors diagnosed in the last 10 years and examined the demographic and clinical variables as well as lifestyle factors associated with lymphedema status. In this cross-sectional study, women with BC (N=866) who had been diagnosed and followed up in the previous 10 years were recruited from the outpatient clinic of 4 general hospitals and one cancer association in China between August 2018 and October 2019. Lymphedema status was determined using the Norman telephone questionnaire as the patient-reported occurrence of hand/lower arm/upper arm swelling. Multiple logistic regression was used to identify risk factors for lymphedema. The median time from BC diagnosis was 4.0 years (interquartile range, 2.0-5.0 years). 81.4% of the patients had undergone mastectomy. The prevalence of arm lymphedema among BC survivors was 49.0%. Age ≥50 years, monthly income <3000 RMB, modified radical mastectomy, postsurgical wound infection, chemotherapy, and radiotherapy were associated with an increased risk of BC-related arm lymphedema, whereas exercise of the affected arm, engagement in active physical activity, and timely reporting of symptoms of infection to a physician decreased the risk (P<0.05). Arm lymphedema is a common complication for postoperative BC survivors within 10 years. It is essential to identify patients at risk of lymphedema based on demographic, clinical, and lifestyle factors and implement interventions targeting modifiable lifestyle behaviors-eg, active physical activity during the postoperative period.