Risk factors for lymphedema after breast surgery: A prospective cohort study in the era of sentinel lymph node biopsy

Article type: Research Article

Authors: Salinas-Huertas, S.^a; | Luzardo-González, A.^a | Vázquez-Gallego, S.^b | Pernas, S.^c | Falo, C.^c | Pla, M.J.^d | Gil-Gil, M.^c | Beranuy-Rodriguez, M.^e | Pérez-Montero, H.^f | Gomila-Sancho, M.^a | Manent-Molina, N.^a | Arencibia-Domínguez, A.^a | Gonzalez-Pineda, B.^a | Tormo-Collado, F.^a | Ortí-Asencio, M.^a | Terra, J.^a | Martinez-Perez, E.^f | Mestre-Jane, A.^a | Campos-Varela, I.^a | Jaraba-Armas, M.^a | Benítez-Segura, A.^g | Campos-Delgado, M.^d | Fernández-Montolí, M.E.^d | Valverde-Alcántara, Y.^h | Rodríguez, A.ⁱ | Campos, G.ⁱ | Guma, A.^j | Ponce-Sebastià, J.^d | Planas-Balagué, R.^a | Catasús-Clavé, M.^a | García-Tejedor, A.^d

Affiliations: [a] Department of Rehabilitation, Hospital Universitari Bellvitge, Idibell, Universitat de Barcelona, Barcelona, Spain | [b] Department of Rehabilitation, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain | [c] Department of Oncology, Multidisciplinary Breast Cancer Unit, Institut Català d’Oncología, Barcelona, Spain | [d] Department of Gynecology, Multidisciplinary Breast Cancer Unit, Hospital Universitari Bellvitge, Idibell, Universitat de Barcelona, Barcelona, Spain | [e] Department of Rehabilitation, Hospital de la Santa Creu i Sant Pau, Universitat de Barcelona, Barcelona, Spain | [f] Department of Oncologic Radiotherapy, Multidisciplinary Breast Cancer Unit, Institut Català d’Oncología, Barcelona, Spain | [g] Department of Nuclear Medicine, Multidisciplinary Breast Cancer Unit, Hospital Universitari Bellvitge, Idibell, Barcelona, Spain | [h] Department of Cancer Prevencion and Control, Institut Català d’Oncología, Barcelona, Spain | [i] Breast Functional Unit, Institut Català d’Oncología, Barcelona, Spain | [j] Department of Radiology, Hospital Universitari Bellvitge, Idibell, Universitat de Barcelona, Barcelona, Spain

Correspondence: [*] Corresponding author: S. Salinas-Huertas, Department of Rehabilitation, Hospital Universitari Bellvitge, Idibell, Universitat de Barcelona, Barcelona, Spain. E-mail: [email protected], [email protected]

Abstract: INTRODUCTION:The Objective was to investigate the incidence of lymphedema after breast cancer treatment and to analyze the risk factors involved in a tertiary level hospital. METHODS:Prospective longitudinal observational study over 3 years post-breast surgery. 232 patients undergoing surgery for breast cancer at our institution between September 2013 and February 2018. Sentinel lymph node biopsy (SLNB) or axillary lymphadenectomy (ALND) were mandatory in this cohort. In total, 201 patients met the inclusion criteria and had a median follow-up of 31 months (range, 1–54 months). Lymphedema was diagnosed by circumferential measurements and truncated cone calculations. Patients and tumor characteristics, shoulder range of motion limitation and local and systemic therapies were analyzed as possible risk factors for lymphedema. RESULTS:Most cases of lymphedema appeared in the first 2 years. 13.9% of patients developed lymphedema: 31% after ALND and 4.6% after SLNB (p < 0.01), and 46.7% after mastectomy and 11.3% after breast-conserving surgery (p < 0.01). The lymphedema rate increased when axillary radiotherapy (RT) was added to radical surgery: 4.3% for SLNB alone, 6.7% for SLNB + RT, 17.6% for ALND alone, and 35.2% for ALND + RT (p < 0.01). In the multivariate analysis, the only risk factors associated with the development of lymphedema were ALND and mastectomy, which had hazard ratios (95% confidence intervals) of 7.28 (2.92–18.16) and 3.9 (1.60–9.49) respectively. CONCLUSIONS:The main risk factors for lymphedema were the more radical surgeries (ALND and mastectomy). The risk associated with these procedures appeared to be worsened by the addition of axillary radiotherapy. A follow-up protocol in patients with ALND lasting at least two years, in which special attention is paid to these risk factors, is necessary to guarantee a comprehensive control of lymphedema that provides early detection and treatment.

Keywords: Breast cancer, lymphedema, sentinel lymph node biopsy, axillary lymphadenectomy, mastectomy

DOI: 10.3233/BD-210043

Journal: Breast Disease, vol. 41, no. 1, pp. 97-108, 2022