Frequency and risk factors for arm lymphedema after multimodal breast conserving treatment of nodal positive breast Cancer – a long-term observation

Julia Rupp, Catarina Hadamitzky, Christoph Henkenberens, Hans Christiansen, Diana Steinmann and Frank Bruns. Radiation Oncology (2019) 14:39

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Frequency and risk factors for arm lymphedema after multimodal breast conserving treatment of nodal positive breast Cancer – a long-term observation

Julia Rupp, Catarina Hadamitzky, Christoph Henkenberens, Hans Christiansen, Diana Steinmann and Frank Bruns. Radiation Oncology (2019) 14:39

Background: Arm-lymphedema is a major complication after breast cancer. Recent studies demonstrate the validity of predicting Breast Cancer Related Lymphedema (BCRL) by self-reports. We aimed to investigate the rate of BCRL and its risk factors in the long-term using self-reported symptoms.

Methods: Data was collected from 385 patients who underwent multimodal therapy for nodal positive breast cancer, including breast conserving surgery, axillary dissection, and local or locoregional radiotherapy. Two validated questionnaires were used for the survey of BCRL (i.e. LBCQ-D and SDBC-D). These were analysed collectively with retrospective data of our medical records.

Results: 23.5% (n =43) suffered a permanent BCRL (stage II-III) after a median follow-up time of 10.1years (4.9–15.9 years); further 11.5% (n =23) reported at least one episode of reversible BCRL (Stage 0-I) during the follow-up time. 87.1% of the patients with lymphedema developed this condition in the first two years. Adjuvant chemotherapy was a significant risk factor for the appearance of BCRL (p =0.001; 95%-CI 7.7–10.2).

Conclusions: Breast cancer survivors face a high risk of BCRL, particularly if axillary dissection was carried out. Almost 90% of BCRL occurred during the first two years after radiotherapy. Self-report of symptoms seems to be a suitable instrument of early detection of BCRL.

Main findings

  • Median follow-up time was 10.1years. 70 Patients (35%) showed symptoms of BCRL irrespective of duration and severity. Further 13 Patients (6.5%) showed symptoms of breast and/or axillary oedema, but no arm oedema. Of all BCRL patients, eight patients (4%) indicated a completely reversible BCRL (Stage 0) within the first year after radiotherapy. 15 patients (7.5%) had a reversible but recurrent LE (Stage I) and 47 patients (23.5%) indicated a permanent BCRL (Stage II-III). Looking at the time of the first appearance of BCRL, we found out that almost 90% of all arm lymphedemas occurred during the first two years after radiotherapy; towards a slow but continuous increase of BCRL frequency during follow-up time thereafter.
  • Statistically, only chemotherapy could be identified as a significant risk factor (p =0.005). Postoperative complications showed a trend towards significance (p =0.083).
  • Overall BCRL rate of 35% in this survey after a median follow-up time of 10.1 years. The prevalence of lymphedema in our survey decreases markedly, when only patients with permanent BCRL are taken into account (i.e., stage II-III): these severe lymphedemas occurred in 23.5% of the cases.
  • This study could only find a small number of significant risk factors for the occurrence of BCRL: These were adjuvant chemotherapy, postoperative complications and nodal stage in univariate analysis and adjuvant chemotherapy in multivariate analysis [HR=2.5], whereas postoperative complications showed a trend towards significance in multivariate analysis [HR=2.3).
  • The limitations of this study were due to the retrospective analysis and to the subjective report of symptoms. This first aspect generated incomplete information e.g. on time to recurrence and causes of death. Also, the dependence on subjective information without additional clinical examination might have generated so-called “recall bias” with underestimation of lymphedema within a mostly elderly population due to memory lapses or poor capacity of self-inspection.