The effect of lymphatic microsurgical preventive healing approach (LYMPHA) on the development of upper-extremity lymphedema following axillary lymph node dissection in breast cancer patients

Background/Objective: Lymphedema following axillary lymph node dissection (ALND) is a common complication that can negatively impact quality of life as it reduces the functional capacity of the affected arm. It can also predispose patients to serious infectious complications such as limb cellulitis and development of malignancy. The lymphatic microsurgical preventive healing approach (LYMPHA procedure) involves the creation of a lymphatic‐to‐venous bypass at the time of axillary lymph node dissection (ALND) as a means of preventing lymphedema. The goal of our study is to assess the effect of LYMPHA on the development of clinical and subjective post‐operative lymphedema. Methods: This is a prospective longitudinal study in patients with breast cancer who underwent ALND with or without LYMPHA. The incidence of lymphedema was compared between ALND alone and ALND with LYMPHA using descriptive statistics. Limb circumference of both affected and unaffected limbs were measured and used to calculate limb volume by using an equation that converts limb circumference (cm) to volume (cc). Lymphedema was defined as a volume difference of ≥10% between the affected and unaffected limb. Patient symptoms were also assessed and compared between the 2 groups. Patient demographics including age, preoperative body mass index (BMI), smoking history, comorbidities, receipt of neoadjuvant or adjuvant chemotherapy, and receipt of adjuvant radiation were compared between the groups. Results: In our cohort of 139 patients, 104 underwent ALND with LYMPHA, while 35 underwent ALND alone. Of these, 52.5% of patients had documented interlimb circumference measurements. The mean age was 52.6 years old, mean BMI was 30.16 kg/m2, 4 patients (2.9%) had pre‐operative radiation, 102 patients (73.4 %) had post‐operative radiation, 86 patients (61.9 %) had neoadjuvant chemotherapy, 41 and 58 patients (41.7 %) had adjuvant chemotherapy. There were no significant differences between the 2 groups in the above demographics and treatment variables, except those who underwent ALND alone had a significantly higher incidence of diabetes mellitus (25.7% patients with ALND alone vs 11.5% LYMPHA patients (p=0.043)). Based on patient reported symptoms and the need to initiate complete decongestive therapy, 57.1% (n=20) of patients who underwent ALND alone developed lymphedema compared to 26.9% (n=28 patients) of those who had ALND with LYMPHA (p=0.0011). When comparing the relative volume difference, 57.1% (n=8) of ALND alone patients developed lymphedema versus 20.3% (n=12) of LYMPHA patients (p=0.0055). Conclusions: Our data support the universal use of LYMPHA at the time of ALND as a means of preventing upper extremity lymphedema. Further studies are needed to evaluate quality of life and functional differences between those who had LYMPHA and those who did not

The effect of oncoplastic reduction on the incidence of post-operative lymphedema in breast cancer patients undergoing lumpectomy

Purpose: In breast cancer patients with macromastia, breast conservation surgery (BCS) followed by radiation therapy (RT) may be associated with a different complication profile than those without macromastia. Oncoplastic reduction mammoplasty (ORM) aims to reduce breast volume while excising the tumor bed and its margins. Since breast volume was found to be a risk factor for chronic breast lymphedema, this study was performed to determine the impact of ORM on chronic breast lymphedema as well as other complications compared to BCS without ORM. Material & Methods: We performed a retrospective chart review on patients who underwent lumpectomy with RT from 2014 to 2018. Chronic breast lymphedema (CBL) was defined as swelling that persisted \u3e1 year post-RT. Breast volumes (BV) were determined by contoured breast volumes or, if unavailable, estimated by the 95% isodose volumes from the RT treatment planning system. Univariate analysis was used to evaluate patient factors and treatment outcomes in women with BV ≥1300 cc compared to-Evaluate factors associated with ≥1 complication. Identify factors associated with the development of CBL. Results: The total population included 1173 patients: -1122 (95.7%) underwent BCS alone without ORM -51 (4.3%) underwent ORM -733 (62.5%) had a BVcc -440 (37.5%) had BV ≥1300 cc Multivariate regression analysis demonstrated that compared to patients with BV \u3c 1300 cc, patients with BV ≥1300 cc had: -Higher BMI (OR=1.200, P\u3c0.001) -Increased risk of CBL (OR=2.127, P=0.024) -Decreased risk of grade 2 radiation dermatitis (OR=0.457, P=0.002) Conclusion: Our data demonstrates that patients with breast volumes ≥1300 cc were two times more likely to develop CBL. Although patients with ORM had an increased risk for surgical site complications, the ORM procedure may have mitigated their risk for CBL. ORM should be considered at the time of BCS in women with macromastia to reduce their future risk of CBL as there is no cure for this disease.https://scholarlycommons.henryford.com/sarcd2021/1008/thumbnail.jp

Factors Associated with Chronic Breast Lymphedema After Adjuvant Radiation in Women Undergoing Breast Conservation Therapy

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 2017. 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 811 patients were included for analysis. Fifty-seven (7.0%) patients developed breast lymphedema beyond one year. For the entire cohort, mean age was 63.3 years old, mean BMI was 31.21 kg/m2, and mean breast volume was 1195 cc (SD = 643.25 cc). Compared to the cohort that did not develop CBL (n = 754), the CBL cohort (n = 57) had a higher BMI (33.10 kg/m2 vs. 29.84 kg/m2, p\u3c0.001), higher percentage of black race (61.4% vs. 43.8%, P = 0.024), larger breast volume (1504 cc vs. 1081 cc, P\u3c0.001), greater number of lymph nodes taken at time of surgery (3 vs. 1, P\u3c0.001), higher percentage that had underwent ALND (12.3% vs. 5.2%, P = 0.036), and larger size of lumpectomy specimen (118.95 cm3 vs. 96.00 cm3, P = 0.016). The density curve determined that the optimal cutoff for breast volume was around 1300 cc. When accounting for potential confounding variables, multivariate regression analysis revealed that those whose breast volume \u3e 1300 cc (vs. \u3c1300 cc) were 2.5 times more likely to experience breast lymphedema after one year (OR = 2.53, p = 0.005). When volume was evaluated as a continuous variable, regression analysis revealed that for every 1cc increase in breast volume, the risk of breast lymphedema increases by 0.1% (OR = 1.001, P = 0.001). Conclusion: Chronic breast lymphedema presents a clinical concern for women undergoing lumpectomy with postoperative radiation, particularly women with larger breasts. Further studies should focus on preventative strategies, as well as the psychosocial and economic impact of this morbidity

Scratch Collapse Test Localizes Osborne’s Band as the Point of Maximal Nerve Compression in Cubital Tunnel Syndrome

The objective of this study is to demonstrate the utility of the scratch collapse test (SCT) in localizing the point of maximal compression in cubital tunnel syndrome. From January 1, 2004 to December 1, 2005, 64 adult patients with cubital tunnel syndrome were evaluated by a single surgeon. Cubital tunnel syndrome was diagnosed based upon symptoms of numbness, tingling, and/or pain in the ulnar nerve distribution or by the presence of weakness or wasting of the ulnar-innervated intrinsic hand muscles. All diagnoses were confirmed with electrodiagnostic studies. As part of the physical examination, the SCT was performed along three subdivided segments in the region of the cubital tunnel. Results of the SCT were recorded and correlated with intraoperative findings. Of the 64 patients evaluated, 44 had a positive SCT that was either more profound or solely present a few centimeters distal to the medial epicondyle in the region of Osborne’s band. All of these patients subsequently underwent anterior submuscular transposition and were found to have a tight compression point at Osborne’s band corresponding to their preoperative SCT. This study suggests that the scratch collapse test may be a reliable physical examination technique for localizing the point of maximal nerve compression in patients with cubital tunnel syndrome. That point, in this series, corresponded with Osborne’s band