The Risk of Subclinical Breast Cancer-Related Lymphedema by the Extent of Axillary Surgery and Regional Node Irradiation: A Randomized Controlled Trial

Abstract

Purpose: To compare the risk of subclinical breast cancererelated lymphedema (sBCRL) using bioimpedance spectroscopy (BIS) or tape measure (TM) by the extent of axillary surgery and regional nodal irradiation (RNI). Methods and Materials: Patients were randomized to surveillance with TM or BIS. A BIS !6.5 L-Dex units or TM volume change !5 and <10% above presurgical baselines "triggered" sBCRL. The incidence of sBCRL by sentinel node biopsy or axillary lymph node dissection (ALND) with or without RNI was examined for 484 patients. Radiation was categorized as "limited RNI" (axilla level I/II only) or "extensive RNI" (axilla level III or supraclavicular fossa with or without level I/II). Results: At a median follow-up of 20.5 months, 109 of 498 patients (21.9%) triggered sBCRL (BIS 13.5% vs TM 25.6%; P <.001). In patients not receiving RNI, BIS triggered 12.9% of patients undergoing SNB and 25.0% undergoing ALND (P Z .18). Extensive RNI significantly increased triggering with BIS versus no RNI after sentinel node biopsy (SNB; 33.3% vs 12.9%; P Z .03) but not ALND (30.8% vs 25.0%; P Z .69). Triggering by TM was greater than 25% for most subgroups and was inferior to BIS in discriminating the risk of sBCRL by utilization of RNI or axillary surgery. Conclusions: The lower triggering rates with BIS and its better discrimination of the risk of sBCRL by receipt and type of RNI compared with TM support its use for posttreatment surveillance to detect sBCRL and to initiate early intervention. The

Risk factors for breast cancer–related lymphedema in patients undergoing 3 years of prospective surveillance with intervention

“…Regarding treatment, patients undergoing ALND, RNI, and taxane‐based chemotherapy remain at higher risk for chronic lymphedema than others do, even after receiving a preventive compression intervention at onset of subclinical lymphedema. The ALND and RNI findings are consistent with previous research that found less treatment to the axilla (sentinel node biopsy alone) was associated with less incidence of subclinical BCRL than more extensive treatment (ALND or radiation that included level 3 of the axilla or supraclavicular fossa) 47 . The taxane finding is not surprising because taxane‐based chemotherapy was the predominant chemotherapy administered in this study, yet these results contrast with findings from another large prospective study in this population in which taxane‐based chemotherapy was not found to be a risk factor 48 .…”

Prophylactic Use of Compression Sleeves Reduces the Incidence of Arm Swelling in Women at High Risk of Breast Cancer–Related Lymphedema: A Randomized Controlled Trial

“…The compression sleeve prescription used in this trial was tailored to prevent accumulation of extracellular fluid arising from surgery, adjuvant chemotherapy, and radiotherapy. 42,47 and to address gravitational forces that occur while in the upright position. 48 These parameters appeared to be well tolerated, as indicated by the lack of any negative effect on patient-reported outcomes, including arm symptoms.…”

“…As BIS quantifies the extracellular fluid, of which lymph is a component, the higher incidence of swelling detected by BIS is expected. 41,42 The prophylactic use of compression sleeves reduced the incidence of arm swelling to the clinically meaningful target, ie, a reduction of 10% set a priori.…”

Evaluation of apical clips placed during axillary dissection demonstrates potential under‐coverage of axillary radiation therapy target volumes during breast cancer regional nodal irradiation

“…An additional concern regarding more comprehensive coverage of nodal tissue is that it may result in increased lymphoedema toxicity, as previously reported. 18,30 Indeed, the ESTRO guidelines state that an increase in treated volume (beyond old simulator based fields) should be avoided as 'no clinical reason for this exists, and as this might lead to an increase in the dose to OARs'. 9 In addition, it is possible that the use of apical clips might add to surgical toxicity, although we have not noted this, and it might be difficult to evaluate.…”