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BACKGROUND: Breast cancer-related lymphedema (BRCL) is one of the most common causes of upper extremity (UE) lymphedema in developed nations and substantially impacts health-related quality of life. To advance our understanding of the epidemiology and treatment of BRCL, rigorously developed and validated patient-reported outcome measures (PROMs) are needed. This study aimed to demonstrate the iterative content validity of a modular UE lymphedema-specific PROM called the LYMPH-Q UE module. METHODS: A multi-step iterative qualitative approach was used. Semi-structured interview data from in-depth qualitative interviews with adult women (18 years and older) with BCRL were used to develop the first set of the LYMPH-Q UE scales. The content validity of these scales was demonstrated with patient and clinician feedback. Over the course of cognitive debriefing interviews, additional concepts of lymphedema worry and impact on work were identified as missing from the LYMPH-Q UE module. Subsequently, two new qualitative studies (a focus group and in-depth concept elicitation interviews with patients) were conducted, and two new scales were developed to measure lymphedema worry and impact on work life and their content validity was demonstrated. RESULTS: Qualitative data from in-depth and cognitive interviews with 15 (age 40-74 years) and 16 (age 38-74 years) women with BRCL, respectively, and feedback from 12 clinical experts, were used to develop and demonstrate the content validity of six LYMPH-Q UE scales measuring symptoms, function, appearance, psychological, information, and arm sleeve. Additionally, data from in-depth interviews with 12 (age 35-72 years) women with UE lymphedema and four focus groups (n = 16 women; age 35-74 years) was used to develop and assess the content validity of two new LYMPH-Q UE scales measuring lymphedema worry and impact on work life. The content validity of the previously established six scales was also demonstrated in these subsequent qualitative studies. CONCLUSION: The LYMPH-Q UE is a modular PROM developed using international guidelines for PROM development and can be used in clinical practice, research, and quality improvement to enhance patient-centered shared decision-making. This study's innovative and iterative approach to content validation demonstrates that the LYMPH-Q UE is a comprehensive measure that includes important concepts relevant to patients with UE lymphedema.
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Medición de Resultados Informados por el Paciente , Investigación Cualitativa , Calidad de Vida , Extremidad Superior , Humanos , Femenino , Persona de Mediana Edad , Calidad de Vida/psicología , Extremidad Superior/fisiopatología , Anciano , Entrevistas como Asunto , Adulto , Reproducibilidad de los Resultados , Linfedema/psicología , Linfedema/diagnóstico , Linfedema/terapia , Linfedema del Cáncer de Mama/terapia , Linfedema del Cáncer de Mama/diagnóstico , Linfedema del Cáncer de Mama/psicología , Grupos Focales , Neoplasias de la Mama/complicaciones , Psicometría/métodos , Psicometría/instrumentaciónRESUMEN
Breast cancer-related lymphedema (BCRL) is characterized by skin changes, swelling, fibrosis, and recurrent skin infections. Clinical studies have suggested that lymphedema results in skin barrier defects; however, the underlying cellular mechanisms and the effects of bacterial contamination on skin barrier function remain unknown. In matched biopsies from patients with unilateral BCRL, we observed decreased expression of FLG and the tight junction protein ZO-1 in skin affected by moderate lymphedema or by subclinical lymphedema in which dermal backflow of lymph was identified by indocyanine green lymphography, relative to those in the controls (areas without backflow and from the unaffected arm). In vitro stimulation of keratinocytes with lymph fluid obtained from patients undergoing lymphedema surgery led to the same changes as well as increased expression of keratin 14, a marker of immature keratinocytes. Finally, using mouse models of lymphedema, we showed that similar to the clinical scenario, the expression of skin barrier proteins was decreased relative to that in normal skin and that colonization with Staphylococcus epidermidis bacteria amplified this effect as well as lymphedema severity. Taken together, our findings suggest that lymphatic fluid stasis contributes to skin barrier dysfunction in lymphedema.
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Introduction: Lymphedema is a major public health issue for many women undergoing breast cancer treatment. Although weight loss has been reported to be beneficial in the treatment of lymphedema, no studies to date have examined the use of GLP-1RAs for the treatment of secondary lymphedema. This case report describes a patient who experienced significant resolution of her breast cancer-related lymphedema after initiation of a GLP-1RA for weight loss. Main symptoms and/or important clinical findings: Nine months postoperatively the patient developed arm swelling and disability. While on adjuvant chemo and hormonal therapy, her weight increased dramatically and peaked 4 years later. Corresponding to her weight gain was significant worsening of her symptoms. The main diagnoses therapeutic interventions and outcomes: Due to adjuvant cancer-related weight gain and inability to lose weight with diet and exercise, she was referred for evaluation and diagnosed with lymphedema. The patient started treatment with a Glucagon-like peptide 1 receptor agonist and lost 24% of her body weight over the next 13 months. The improvement in her lymphedema mirrored her weight loss. Her limb volume difference dropped from 10.3% down to 3.4% and she no longer required a compression garment. Her imaging demonstrated return of lymphatic pumping and she experienced a significant improvement in quality of life, assessed by a validated lymphedema-specific patient reported outcome (PROM). She remains on hormonal therapy, no longer needs compression and is back to regular exercise without impairment. Conclusions: GLP-1 RAs provide a potential medical option for many patients struggling with weight gain and lymphedema. We have observed by all objective measures a significant reduction in lymphedema and the elimination of compression in the case presented as a direct result of GLP-1 RA. This may also reduce a patient's BMI to the point where they become a good candidate for lymphovenous bypass or vascularized lymph node transplant when indicated.
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Patients undergoing extensive lymph node dissection and radiation are at high risk for not only lymphedema but also painful contracture. In a standard lymphadenectomy, immediate lymphatic reconstruction using a lymphovenous bypass is effective in reconstructing the lymphatic defect. However, a more aggressive nodal clearance leaves the patient with a large cavity and skeletonized neurovascular structures, often resulting in severe contracture, pain, cosmetic deformity, and venous stricture. Adjuvant radiotherapy to the nodal bed can lead to severe and permanent disability despite physical therapy. Typically, these patients are referred to us after the fact, where surgery will rarely restore the patient to normal function. In an effort to avoid lymphedema and contracture, we have been reconstructing both the lymphatic and soft tissue defect during lymphadenectomy, using vascularized omentum lymphatic transplant (VOLT). A total of 13 patients underwent immediate reconstruction with VOLT at the time of axillary (nâ =â 8; 61.5%) or groin (nâ =â 5; 38.5%) dissection. No postoperative complications were observed. The mean follow-up time was 15.1â ±â 12.5 months. Only one lower extremity patient developed mild lymphedema (11% volume differential), with excellent scores in validated patient-reported outcomes. All patients maintained full range of motion with no pain. None of the 13 patients required a compression garment. Immediate lymphatic reconstruction with VOLT is a promising procedure for minimizing the risk of lymphedema and contracture in the highest risk patients undergoing particularly extensive lymph node dissection and radiotherapy.
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BACKGROUND: Prior studies have shown an increased risk of complications and flap loss with the use of vein grafts in microsurgery. We hypothesize that indication for use of a vein graft can affect flap complications and loss rates. METHODS: We performed a retrospective review of all patients at our institution from 2010 to 2020 who underwent free flap reconstruction and required use of a vein graft. Indications for vein grafting included: salvage of flap during primary operation after microvascular compromise, augmentation of flow during primary operation, lengthening of the flap pedicle during the primary operation, and salvage of the flap during a secondary salvage operation after microvascular compromise. RESULTS: A total of 79 patients met the study inclusion criteria. There were significant differences among the vein graft indication groups and the following: area of reconstruction (p = 0.002), vein graft length (p = 0.018), vessels grafted (p = 0.001), vein graft donor site (p = 0.011), and total flap loss (p = 0.047). Of the four indications for vein grafting, salvage of the flap during secondary salvage operation after microvascular compromise had the highest rate of total flap loss (26.7%). There were no significant associations between other flap complications and vein graft indications. CONCLUSION: Vein graft use in the primary reconstructive setting is efficacious, with low risk of thrombosis. Use in secondary procedures, however, is associated with higher rates of total flap loss, likely due to the thrombotic process, which was initiated prior to the use of the graft resulting in the salvage procedure and not secondary to the graft itself.
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Colgajos Tisulares Libres , Microcirugia , Procedimientos de Cirugía Plástica , Complicaciones Posoperatorias , Venas , Humanos , Colgajos Tisulares Libres/irrigación sanguínea , Estudios Retrospectivos , Masculino , Femenino , Procedimientos de Cirugía Plástica/métodos , Persona de Mediana Edad , Venas/trasplante , Microcirugia/métodos , Complicaciones Posoperatorias/cirugía , Supervivencia de Injerto , Adulto , Anciano , Resultado del Tratamiento , Terapia Recuperativa/métodosRESUMEN
BACKGROUND: Prepectoral implant placement for postmastectomy breast reconstruction has increased in recent years. Benefits of prepectoral reconstruction may include lack of animation deformities and reduced postoperative pain, but its complication profile is currently unclear. This study aimed to examine the complication profile of prepectoral tissue expanders (TEs) to determine factors associated with TE loss. METHODS: A retrospective review was performed to identify all patients who underwent immediate prepectoral TE reconstruction from January 2018 to June 2021. The decision to use the prepectoral technique was based on mastectomy skin quality and patient comorbidities. Patient demographics, comorbidities, and operative details were evaluated. Outcomes of interest included TE loss, seroma, hematoma, infection/cellulitis, mastectomy skin flap necrosis requiring revision, and TE exposure. Logistic regression analysis was performed to identify factors associated with TE loss. RESULTS: The study identified 1225 TEs. The most frequent complications were seroma (8.7%, n = 106), infection/cellulitis (8.2%, n = 101), and TE loss (4.2%, n = 51). Factors associated with TE loss in the univariate analysis included ethnicity, history of smoking, body mass index, mastectomy weight, and neoadjuvant chemotherapy. In the multivariate regression analysis, only mastectomy weight had a positive association with TE loss (odds ratio, 1.001; p = 0.016). CONCLUSION: Prepectoral two-stage breast reconstruction can be performed safely with an acceptable early complication profile. The study data suggest that increasing mastectomy weight is the most significant factor associated with TE loss. Further research examining the quality of the soft tissue envelope and assessing patient-reported outcomes would prove beneficial.
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Implantación de Mama , Implantes de Mama , Neoplasias de la Mama , Mamoplastia , Humanos , Femenino , Mastectomía/efectos adversos , Dispositivos de Expansión Tisular/efectos adversos , Neoplasias de la Mama/cirugía , Neoplasias de la Mama/complicaciones , Celulitis (Flemón)/complicaciones , Celulitis (Flemón)/cirugía , Seroma/cirugía , Mamoplastia/efectos adversos , Mamoplastia/métodos , Estudios Retrospectivos , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugía , Implantes de Mama/efectos adversos , Implantación de Mama/efectos adversos , Implantación de Mama/métodosRESUMEN
BACKGROUND: Surgical treatment of lymphedema has outpaced coding paradigms. In the setting of ambiguity regarding coding for physiologic procedures [lymphovenous bypass (LVB) and vascularized lymph node transplant (VLNT)], we hypothesized that there would be variation in commercial reimbursement based on coding pattern. METHODS: The authors performed a cross-sectional analysis of 2021 nationwide hospital pricing data for 21 CPT codes encompassing excisional (direct excision, liposuction), physiologic (LVB, VLNT), and ancillary (lymphangiography) procedures. Within-hospital ratios (WHRs) and across-hospital ratios (AHRs) for adjusted commercial rates per CPT code quantified price variation. Mixed effects linear regression modeled associations of commercial rate with public payer (Medicare and Medicaid), self-pay, and chargemaster rates. RESULTS: A total of 270,254 commercial rates, including 95,774 rates for physiologic procedures, were extracted from 2863 hospitals. Lymphangiography codes varied most in commercial price (WHR, 1.76 to 3.89; AHR, 8.12 to 44.38). For physiologic codes, WHRs ranged from 1.01 (VLNT; free omental flap) to 3.03 (LVB; unlisted lymphatic procedure), and AHRs ranged from 5.23 (LVB; lymphatic channel incision) to 10.36 (LVB; unlisted lymphatic procedure). Median adjusted commercial rates for excisional procedures ($3635.84) were higher than for physiologic procedures ($2560.40; P < 0.001). Commercial rate positively correlated with Medicare rate for all physiologic codes combined, although regression coefficients varied by code. CONCLUSIONS: Commercial payer-negotiated rates for physiologic procedures were highly variable both within and across hospitals, reflective of variation in CPT codes. Physiologic procedures may be undervalued relative to excisional procedures. Consistent coding nomenclature should be developed for physiologic and ancillary procedures.
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Vasos Linfáticos , Linfedema , Anciano , Humanos , Estados Unidos , Medicare , Consenso , Estudios Transversales , Linfedema/cirugía , Vasos Linfáticos/cirugíaRESUMEN
BACKGROUND: Prepectoral tissue expander (TE) placement for two-stage postmastectomy reconstruction is usually performed in conjunction with insertion of acellular dermal matrix (ADM). However, the effects of ADM use on TE loss or other early complications remain unknown. Therefore, the aim of this study was to compare early postoperative complications in patients who underwent prepectoral breast implant reconstruction with or without ADM use. METHODS: The authors performed a retrospective cohort study of all patients at their institution who underwent prepectoral breast reconstruction from January of 2018 to June of 2021. The primary outcome was TE loss within 90 days of surgery; secondary outcomes included other complications such as infection, TE exposure, mastectomy skin flap necrosis requiring revision, and seroma. RESULTS: Data on 714 patients with 1225 TEs (1060 with ADM and 165 without) were analyzed. Baseline demographics did not differ by ADM use, although mastectomy breast tissue weight was higher in patients without ADM (750.3 g versus 540.8 g; P < 0.001). Rates of TE loss were similar in reconstructions with (3.8%) ADM and without (6.7%; P = 0.09). We also did not find differences in the rates of secondary outcomes between cohorts. CONCLUSIONS: ADM use had no statistically significant effect on early complication rates among patients undergoing breast reconstruction with prepectoral TEs. Still, this study was underpowered, and data trended toward statistical significance; thus, larger studies are required in the future. Additional research and randomized studies should focus on larger cohorts and examine long-term complications such as capsular contracture and implant malposition. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
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Dermis Acelular , Implantación de Mama , Implantes de Mama , Neoplasias de la Mama , Mamoplastia , Humanos , Femenino , Mastectomía/efectos adversos , Neoplasias de la Mama/cirugía , Neoplasias de la Mama/complicaciones , Estudios Retrospectivos , Mamoplastia/efectos adversos , Implantación de Mama/efectos adversos , Implantes de Mama/efectos adversos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiologíaRESUMEN
OBJECTIVES: The aim of this study was to compare postoperative outcomes between biologic and synthetic reconstructions after chest wall resection in a matched cohort. METHODS: All patients who underwent reconstruction after full-thickness chest wall resection from 2000 to 2022 were reviewed and stratified by prosthesis type (biologic or synthetic). Biologic prostheses were of biologic origin or were fully absorbable and incorporable. Integer matching was performed to reduce confounding. The study end point was surgical site complications requiring reoperation. Multivariable analysis was performed to identify associated risk factors. RESULTS: In total, 438 patients underwent prosthetic chest wall reconstruction (unmatched: biologic, n = 49; synthetic, n = 389; matched: biologic, n = 46; synthetic, n = 46). After matching, the median (interquartile range) defect size was 83 cm2 (50-142) for the biologic group and 90 cm2 (48-146) for the synthetic group (P = 0.97). Myocutaneous flaps were used in 33% of biologic reconstructions (n = 15) and 33% of synthetic reconstructions (n = 15) in the matched cohort (P = 0.99). The incidence of surgical site complications requiring reoperation was not significantly different between biologic and synthetic reconstructions in the unmatched (3 [6%] vs 29 [7%]; P = 0.99) and matched (2 [4%] vs 4 [9%]; P = 0.68) cohorts. On the multivariable analysis, operative time [adjusted odds ratio (aOR) = 1.01, 95% confidence interval (CI), 1.00-1.01; P = 0.006] and operative blood loss (aOR = 1.00, 95% CI, 1.00-1.00]; P = 0.012) were associated with higher rates of surgical site complications requiring reoperation; microvascular free flaps (aOR = 0.03, 95% CI, 0.00-0.42; P = 0.024) were associated with lower rates. CONCLUSIONS: The incidence of surgical site complications requiring reoperation was not significantly different between biologic and synthetic prostheses in chest wall reconstructions.
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Productos Biológicos , Pared Torácica , Humanos , Pared Torácica/cirugía , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/cirugía , Complicaciones Posoperatorias/etiología , Resultado del Tratamiento , Prótesis e Implantes/efectos adversos , Estudios RetrospectivosRESUMEN
Background: Since its introduction for autologous breast reconstruction in 2010, the profunda artery perforator (PAP) flap has emerged as a preferred choice when an abdominal flap is suboptimal. The traditional transverse design (tPAP) was popularized, given the inconspicuous donor scar. A diagonal design (dPAP) has since evolved to address some of the shortcomings of the tPAP. The authors aimed to compare outcomes of tPAP/dPAP flaps harvested for breast reconstruction by a single surgeon. Methods: A retrospective review was conducted from 2017 to 2022 of patients undergoing tPAP versus dPAP-based breast reconstruction by a single surgeon at a tertiary cancer center. Patient variables and operative variables were assessed. Need for additional symmetrizing breast procedures were compared. Complications and BREAST-Q patient-reported outcome measures were analyzed. Results: Thirty-nine flaps were used to reconstruct 35 breasts in 24 patients. Average follow-up for the group was 1.8 years. The groups were similar with respect to demographics. The majority of dPAP flaps had two perforators, whereas most tPAP flaps had one perforator. The dPAP flaps had greater average weights, width, and overall surface area. There were no cases of partial/total flap loss. Complications and PROM results were similar between the two groups. Conclusions: The dPAP design allows for a larger skin paddle and greater tissue harvest and capture of cutaneous perforators, without increasing the risk of complications or compromising satisfaction. It should be considered as a viable option in patients unable to undergo abdominal-based reconstruction. Additional patients and multi-institutional efforts are necessary to better compare advantages of either design.
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BACKGROUND: Textured implants have been linked to breast implant-associated anaplastic large-cell lymphoma. Patients who undergo explantation have options for reconstruction, but data on safety and patient-reported outcomes (PROs) is limited. The purpose of this study was to classify complications and PROs in patients opting for surgical management of textured implants. METHODS: Complication rates and BREAST-Q scores were compared between (i) asymptomatic patients who underwent conversion from textured to smooth implants (n=224), (ii) symptomatic patients who underwent conversion from textured to smooth implants (n=83), (iii) patients who underwent explantation without replacement (n=44), and (iv) patients who underwent replacement with autologous reconstruction (n=33). Linear regression examined PROs controlling for clinical and surgical variables. RESULTS: Overall complication rates in 384 patients (637 implants) differed across groups (p=0.034) with the highest rate (25%) in patients who underwent explantation without replacement. These patients were specifically more impacted by minor complications, notably seroma. Capsulectomy extent did not significantly impact complications. Asymptomatic and symptomatic smooth implant patients had improvements in satisfaction with breasts (<0.05). Autologous reconstruction patients had significant improvements in satisfaction with breasts sustained after 3 months postoperative (p<0.01) and sexual well-being sustained after 6-months postoperative (p<0.05). Patients who underwent removal without replacement had lower physical well-being of the chest scores at ≥1 year than the other groups. CONCLUSIONS: Replacement of textured implants with smooth implants or flaps is safe and is associated with improved satisfaction with breasts and quality of life. The degree of capsulectomy does not appear to impact the incidence of perioperative complications.
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BACKGROUND: Acellular dermal matrix (ADM) is frequently utilized in prepectoral breast reconstruction, but few studies have examined the role of ADM type in complication risk. OBJECTIVES: This study was performed to determine the impact of ADM type on early complication rates in 2-stage alloplastic prepectoral breast reconstruction. METHODS: We performed a cohort examination of all patients who underwent mastectomy with immediate 2-stage alloplastic prepectoral breast reconstruction with ADM support at Memorial Sloan Kettering Cancer Center from 2018 to 2021. ADM types utilized included AlloDerm (LifeCell Corporation, Branchburg, NJ), FlexHD (MTF Biologics, Edison, NJ), and SurgiMend (Integra LifeSciences Corporation, Princeton, NJ). Complication rates based on the number of tissue expanders (TEs) were determined for each ADM type. Performance of multivariate logistic regression determined the impact of ADM type on complication risk after accounting for confounders. RESULTS: Overall, 726 patients (1054 TEs: 194 AlloDerm, 93 FlexHD, 767 SurgiMend) were included. The 3 cohorts differed in terms of mastectomy type (nipple-sparing: 23.5% of AlloDerm, 33.3% of FlexHD, 19.1% of SurgiMend, P = .038); ADM perforation (perforated: 94.8% of AlloDerm, 98.2% of FlexHD, 100% of SurgiMend, P < .001); and ADM size (AlloDerm: 153.2 cm2 [37.6], SurgiMend: 198.7 cm2 [10.4], FlexHD: 223.7 cm2 [37.9], P < .001). On univariate examination, no differences existed between ADM types for seroma, infection, exposure, malposition, or TE loss. Additionally, after adjustment for confounders with multivariate regression, no ADM type had higher odds of TE loss. CONCLUSIONS: In this large cohort of prepectoral reconstruction patients, ADM type did not significantly affect the risk of complications. Additional prospective studies are warranted to better evaluate ADM choice for prepectoral breast reconstruction.
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Dermis Acelular , Implantación de Mama , Implantes de Mama , Neoplasias de la Mama , Colágeno , Mamoplastia , Humanos , Femenino , Mastectomía/efectos adversos , Implantación de Mama/efectos adversos , Neoplasias de la Mama/cirugía , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Mamoplastia/efectos adversos , Estudios de Cohortes , Implantes de Mama/efectos adversosRESUMEN
Importance: Breast cancer-related lymphedema (BCRL) is a common complication of axillary lymph node dissection (ALND) but can also develop after sentinel lymph node biopsy (SLNB). Several models have been developed to predict the risk of disease development before and after surgery; however, these models have shortcomings that include the omission of race, inclusion of variables that are not readily available to patients, low sensitivity or specificity, and lack of risk assessment for patients treated with SLNB. Objective: To create simple and accurate prediction models for BCRL that can be used to estimate preoperative or postoperative risk. Design, Setting, and Participants: In this prognostic study, women with breast cancer who underwent ALND or SLNB from 1999 to 2020 at Memorial Sloan Kettering Cancer Center and the Mayo Clinic were included. Data were analyzed from September to December 2022. Main Outcomes and Measures: Diagnosis of lymphedema based on measurements. Two predictive models were formulated via logistic regression: a preoperative model (model 1) and a postoperative model (model 2). Model 1 was externally validated using a cohort of 34â¯438 patients with an International Classification of Diseases diagnosis of breast cancer. Results: Of 1882 included patients, all were female, and the mean (SD) age was 55.6 (12.2) years; 80 patients (4.3%) were Asian, 190 (10.1%) were Black, 1558 (82.8%) were White, and 54 (2.9%) were another race (including American Indian and Alaska Native, other race, patient refused to disclose, or unknown). A total of 218 patients (11.6%) were diagnosed with BCRL at a mean (SD) follow-up of 3.9 (1.8) years. The BCRL rate was significantly higher among Black women (42 of 190 [22.1%]) compared with all other races (Asian, 10 of 80 [12.5%]; White, 158 of 1558 [10.1%]; other race, 8 of 54 [14.8%]; P < .001). Model 1 included age, weight, height, race, ALND/SLNB status, any radiation therapy, and any chemotherapy. Model 2 included age, weight, race, ALND/SLNB status, any chemotherapy, and patient-reported arm swelling. Accuracy was 73.0% for model 1 (sensitivity, 76.6%; specificity, 72.5%; area under the receiver operating characteristic curve [AUC], 0.78; 95% CI, 0.75-0.81) at a cutoff of 0.18, and accuracy was 81.1% for model 2 (sensitivity, 78.0%; specificity, 81.5%; AUC, 0.86; 95% CI, 0.83-0.88) at a cutoff of 0.10. Both models demonstrated high AUCs on external (model 1: 0.75; 95% CI, 0.74-0.76) or internal (model 2: 0.82; 95% CI, 0.79-0.85) validation. Conclusions and Relevance: In this study, preoperative and postoperative prediction models for BCRL were highly accurate and clinically relevant tools comprised of accessible inputs and underscored the effects of racial differences on BCRL risk. The preoperative model identified high-risk patients who require close monitoring or preventative measures. The postoperative model can be used for screening of high-risk patients, thus decreasing the need for frequent clinic visits and arm volume measurements.
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Neoplasias de la Mama , Linfedema , Femenino , Humanos , Persona de Mediana Edad , Masculino , Neoplasias de la Mama/patología , Incidencia , Estudios de Factibilidad , Factores Raciales , Axila/cirugía , Escisión del Ganglio Linfático/efectos adversos , Biopsia del Ganglio Linfático Centinela , Linfedema/epidemiología , Linfedema/etiología , Linfedema/patologíaRESUMEN
OBJECTIVE: To conduct a randomized controlled trial (RCT) on the efficacy of immediate lymphatic reconstruction (ILR) for decreasing the incidence of breast cancer-related lymphedema (BCRL) after axillary lymph node dissection (ALND). BACKGROUND: Despite encouraging results in small studies, an appropriately powered RCT on ILR has not been performed. METHODS: Women undergoing ALND for breast cancer were randomized in the operating room 1:1 to either ILR, if technically feasible, or no ILR (control). The ILR group underwent lymphatic anastomosis to a regional vein using microsurgical techniques; control group had no repair and cut lymphatics were ligated. Relative volume change (RVC), bioimpedance, quality of life (QoL), and compression use were evaluated at baseline and every 6 months postoperatively up to 24 months. Indocyanine green (ICG) lymphography was performed at baseline and 12 and 24 months postoperatively. The primary outcome was the incidence of BCRL, defined as ≥10% RVC from baseline in the affected extremity at 12-, 18-, or 24-month follow-up. RESULTS: Of 72 patients randomized to ILR and 72 to control from January 2020 to March 2023, our preliminary analysis includes 99 patients with 12-month follow-up, 70 with 18-month follow-up, and 40 with 24-month follow-up. The cumulative incidence of BCRL was 9.5% in the ILR group and 32% in the control group ( P =0.014). The ILR group had lower bioimpedance values, decreased compression usage, better lymphatic function on ICG lymphography, and better QoL than the control group. CONCLUSIONS: Preliminary results of our RCT show that ILR after ALND decreases BCRL incidence. Our goal is to finish the accrual of 174 patients with 24-month follow-up.
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Linfedema del Cáncer de Mama , Neoplasias de la Mama , Linfedema , Femenino , Humanos , Incidencia , Linfedema del Cáncer de Mama/epidemiología , Linfedema del Cáncer de Mama/etiología , Linfedema del Cáncer de Mama/prevención & control , Neoplasias de la Mama/patología , Escisión del Ganglio Linfático/efectos adversos , Verde de Indocianina , Linfedema/etiología , Axila/cirugíaRESUMEN
PURPOSE: To elicit a patient-prioritized agenda and preferences for upper extremity lymphedema (LE) research. METHODS: Focus group sessions (FGs) were conducted with English-speaking, adult women (18 years and older) with breast cancer-related LE (BCRL) seeking conservative or surgical care at two tertiary cancer centers in Ontario, Canada. An interview guide was used; women were asked to describe health-related quality of life (HRQL) outcomes that mattered the most to them, followed by their preferences for research study design and for providing patient-reported outcomes measure (PROM) data. Inductive content analysis was used to identify themes and subthemes. RESULTS: A total of 16 women participated in 4 FG sessions (55 ± 9.5 years) and described the impact of LE on their appearance, physical, psychosocial, and sexual well-being. Women emphasized that psychosocial well-being was often not discussed in clinical care and that they were poorly informed of LE risk and care options. Most women said that they would not be willing to be randomized to surgical versus conservative management of LE. They also expressed a preference to complete PROM data electronically. All women emphasized the value of having an open text option alongside PROMs to expand on their concerns. CONCLUSION: Patient centeredness is key to generating meaningful data and ensuring ongoing engagement in clinical research. In LE, comprehensive PROMs that measure a range of HRQL concerns, especially psychosocial well-being, should be considered. Women with BCRL are reluctant to be randomized to conservative care when a surgical option is available, resulting in implications for planning trial sample size and recruitment.
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Neoplasias de la Mama , Linfedema , Adulto , Femenino , Humanos , Neoplasias de la Mama/complicaciones , Neoplasias de la Mama/cirugía , Escisión del Ganglio Linfático , Linfedema/cirugía , Ontario , Calidad de Vida , Extremidad Superior , Persona de Mediana EdadRESUMEN
Purpose of Review: This review aims to summarize the current knowledge regarding the pharmacological interventions studied in both experimental and clinical trials for secondary lymphedema. Recent Findings: Lymphedema is a progressive disease that results in tissue swelling, pain, and functional disability. The most common cause of secondary lymphedema in developed countries is an iatrogenic injury to the lymphatic system during cancer treatment. Despite its high incidence and severe sequelae, lymphedema is usually treated with palliative options such as compression and physical therapy. However, recent studies on the pathophysiology of lymphedema have explored pharmacological treatments in preclinical and early phase clinical trials. Summary: Many potential treatment options for lymphedema have been explored throughout the past two decades including systemic agents and topical approaches to decrease the potential toxicity of systemic treatment. Treatment strategies including lymphangiogenic factors, anti-inflammatory agents, and anti-fibrotic therapies may be used independently or in conjunction with surgical approaches.
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OBJECTIVE: Pedicled flaps (PFs) have historically served as the preferred option for reconstruction of large chest wall defects. More recently, the indications for microvascular-free flaps (MVFFs) have increased, particularly for defects in which PFs are inadequate or unavailable. We sought to compare oncologic and surgical outcomes between MVFFs and PFs in reconstructions of full-thickness chest wall defects. METHODS: We retrospectively identified all patients who underwent chest wall resection at our institution from 2000 to 2022. Patients were stratified by flap reconstruction. End points were defect size, rate of complete resection, rate of local recurrence, and postoperative outcomes. Multivariable analysis was performed to identify factors associated with complications at 30 days. RESULTS: In total, 536 patients underwent chest wall resection, of whom 133 had flap reconstruction (MVFF, n = 28; PF, n = 105). The median (interquartile range) covered defect size was 172 cm2 (100-216 cm2) for patients receiving MVFF versus 109 cm2 (75-148 cm2) for patients receiving PF (P = .004). The rate of R0 resection was high in both groups (MVFF, 93% [n = 26]; PF, 86% [n = 90]; P = .5). The rate of local recurrence was 4% in MVFF patients (n = 1) versus 12% in PF patients (n = 13, P = .3). Postoperative complications were not statistically different between groups (odds ratio for PF, 1.37; 95% confidence interval, 0.39-5.14]; P = .6). Operative time >400 minutes was associated with 30-day complications (odds ratio, 3.22; 95% confidence interval, 1.10-9.93; P = .033). CONCLUSIONS: Patients with MVFFs had larger defects, a high rate of complete resection, and a low rate of local recurrence. MVFFs are a valid option for chest wall reconstructions.
Asunto(s)
Colgajos Tisulares Libres , Procedimientos de Cirugía Plástica , Procedimientos Quirúrgicos Torácicos , Pared Torácica , Humanos , Colgajos Tisulares Libres/efectos adversos , Colgajos Tisulares Libres/cirugía , Pared Torácica/cirugía , Estudios Retrospectivos , Procedimientos de Cirugía Plástica/efectos adversosRESUMEN
BACKGROUND: One option to optimize prepectoral tissue expander fill volume while minimizing stress on mastectomy skin flaps is to use air as an initial fill medium, with subsequent exchange to saline during postoperative expansion. The authors compared complications and early patient-reported outcomes (PROs) based on fill type in prepectoral breast reconstruction patients. METHODS: Prepectoral breast reconstruction patients who underwent intraoperative tissue expansion with air or saline from 2018 to 2020 were reviewed to assess fill-type utilization. The primary endpoint was expander loss; secondary endpoints included seroma, hematoma, infection/cellulitis, full-thickness mastectomy skin flap necrosis requiring revision, expander exposure, and capsular contracture. PROs were assessed with the BREAST-Q Physical Well-Being of the Chest scale 2 weeks postoperatively. Propensity-matching was performed as a secondary analysis. RESULTS: Of 560 patients (928 expanders) included in the analysis, 372 had devices initially filled with air (623 expanders), and 188 with saline (305 expanders). No differences were observed for overall rates of expander loss (4.7% versus 3.0%, P = 0.290) or overall complications (22.5% versus 17.7%, P = 0.103). No difference in BREAST-Q scores was observed ( P = 0.142). Utilization of air-filled expanders decreased substantially over the last study year. After propensity matching, no differences in loss, other complications, or PROs were observed across cohorts. CONCLUSIONS: Tissue expanders initially filled with air seem to have no significant advantage over saline-filled expanders in maintaining mastectomy skin flap viability or PROs, including after propensity matching. These findings can help guide choice of initial tissue expander fill type. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
Asunto(s)
Implantes de Mama , Neoplasias de la Mama , Mamoplastia , Humanos , Femenino , Mastectomía/efectos adversos , Mamoplastia/efectos adversos , Neoplasias de la Mama/cirugía , Neoplasias de la Mama/complicaciones , Estudios Retrospectivos , Expansión de Tejido/efectos adversos , Dispositivos de Expansión Tisular/efectos adversos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & control , Implantes de Mama/efectos adversosRESUMEN
BACKGROUND: Current predictive models of lymphedema risk cannot predict with 100% certainty which patients will go on to develop lymphedema and which will not. Patient-specific anatomic and physiologic differences may be the missing factor. The authors hypothesize that patients with accessory lymphatic pathways may have improved lymphatic drainage, resulting in smaller limb volumes. METHODS: The authors reviewed indocyanine green (ICG) lymphography images of all patients who presented to their institution for evaluation of breast cancer-related lymphedema. Patients with unilateral upper extremity lymphedema, a full set of bilateral limb measurements, and ICG images of both limbs were included. Other variables of interest included patient demographics and length of follow-up. Patients with accessory pathways were determined independently, and conflicts were resolved with discussion. Abnormal images were also evaluated for common drainage pathways. RESULTS: Thirty patients were identified as having accessory lymphatic drainage pathways. These patients had significantly smaller limb volume differences [8.19% (SD, 11.22)] compared with patients who did not exhibit these pathways [20.74% (SD, 19.76); P < 0.001]. The most common pathway was absence or rerouting of the radial bundle to the ulnar or volar bundles ( n = 16). CONCLUSIONS: The ability to create accessory lymphatic drainage pathways may be associated with improved lymphatic drainage, resulting in smaller limb volumes. Furthermore, certain drainage pathways appear to be more common than others. Description of these pathways should be considered for inclusion in ICG lymphography image grading criteria. Further study is needed to clarify the nature of these pathways and whether these pathways affect subjective symptoms and quality of life. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.