Li Zou, Feng‑hua Liu, Pei‑pei Shen, Yan Hu, Xiao‑qian Liu, Ying‑ying Xu, Qi‑liang Pen, Bei Wang, Ya‑qun Zhu, Ye Tian. Breast Cancer (2018) 25:309–314

Main findings

• This study was designed for 2 years follow-up. 387 participants were included.
• The following clinical information was obtained: age, complications, type of pathology, tumor staging, axillary node status, number of axillary nodes removed, type of surgery, body mass index (BMI), and the situation of radiotherapy, chemotherapy and endocrinotherapy.
• Assessment data was taken before surgery, 1, 3, 6, 12, 18 and 24 months post-surgery, respectively, using circumferences and questionnaires.
• The circumference measurements were taken 10 cm above and below the olecranon and an absolute change of 2 cm at any point was defined as criteria for BCRL. The severity of BCRL was graded mild when circumference change was ≦ 4 c , moderate when ≦ 6 cm , and severe when change was more than 6 cm.
• The questionnaire was designed from the report of Norman SA et al.
• Norman SA, Localio AR, Kallan MJ, et al. Risk factors for lymphedema after breast cancer treatment. Cancer Epidemiol Biomark Prev. 2010;19(11):2734–46.
• At every in-person interview, the woman was first asked: “between the date of breast cancer diagnosis and today, did your right and left hands/lower arms/upper arms seemed to differ in size”. To assess the size of the difference, women who noticed any difference in size between the 2 limbs got 1 point and then were asked: “Would you say that, on average, the difference in the size of your hands/ lower arms/upper arms was (1) very slight, you are the only person who would notice this, get 1 point, (2) noticeable to people who know you well but not to strangers, get 2 points or (3) very noticeable, get 3 points”. The score points are added. The diagnosis of BCRL was evaluated as, 1–3 mild edema, 4–6 moderate edema, 7–9 severe edema.
• 323 patients had axillary lymph node dissection (ALND) treatment and 64 patients underwent sentinel lymph node biopsy (SLNB). There were 245 patients who received radiation therapy, all of them had three-dimensional conformal radiation therapy or intensity modulated radiation therapy (IMRT) technology based on CT scanning. 46 patients experienced chest wall irradiation only, 14 people  just received the whole breast radiation and tumor bed boost. The radiation therapeutic fields included chest wall and supraclavicular fossa in 127 patients. Besides, another 58 patients had accepted the whole breast + supraclavicular fossa radiotherapy with tumor bed boost.
• The incidence of lymphedema was slightly higher using the Norman questionnaire than those of the circumference measurement, and the incidence of moderate and severe edema was higher with Norman questionnaire than those of the circumference measurement. There were 7 people who was diagnosed as moderate lymphedema immediately after surgery.
• Risk factors for lymphedema in the upper limb of breast cancer included BMI, type of pathology, the number of lymph node dissection, number of positive lymph nodes, postoperative N and TNM staging, surgical approach, treatment of axillary lymph node.
• Radiation therapy was an independent risk factor of BCRL. They analyzed the differences of radiotherapy dosages and areas, and then we found that areas including supraclavicular fossa could increase the risk of BCRL
• The incidence of BCRL increased more rapidly during the first year post-operation. The incidence of BCRL is still in a slow upward trend in the 2 years after surgery.
• The limitation of this study is that the sample size is relatively small and a further study with a larger sample size is needed.
• Age, hypertension, the number of axillary lymph node detection, chemotherapy, etc., in this study found no correlation with the occurrence and development of BCRL.