title: Residual lymph node disease after neoadjuvant chemotherapy predicts an increased risk of lymphedema in node-positive breast cancer patients.
abstract: BACKGROUND
  Axillary lymph node dissection (ALND) is recommended for patients with clinically node-positive breast cancer and carries a risk of lymphedema>30%. Patients with node-positive breast cancer may consider neoadjuvant chemotherapy, which can reduce node positivity. We sought to determine if neoadjuvant chemotherapy reduced the risk of lymphedema in patients undergoing ALND for node-positive breast cancer.
  
  
  METHODS
  The 229 patients who underwent unilateral ALND and chemotherapy were divided into two groups: 30% (68/229) had neoadjuvant and 70% (161/229) had adjuvant chemotherapy. Prospective arm volumes were measured via perometry preoperatively and at 3- to 7-month intervals after surgery. Lymphedema was defined as relative volume change (RVC)≥10%, >3 months from surgery. Kaplan-Meier curves and multivariate regression models were used to identify risk factors for lymphedema.
  
  
  RESULTS
  Fifteen percent (10/68) of neoadjuvant patients compared with 23% (37/161) of adjuvant patients developed RVC≥10% (hazard ratio=0.76, p=0.39). For all patients, body mass index was significantly associated with lymphedema (p=0.0003). For neoadjuvant patients, residual lymph node disease after chemotherapy was associated with a ninefold greater risk of lymphedema compared to those without residual disease (p=0.038).
  
  
  CONCLUSIONS
  Patients who underwent neoadjuvant chemotherapy did not have a statistically significant reduction in risk of lymphedema. Among patients who receive neoadjuvant chemotherapy, residual lymph node disease predicted a greater risk of lymphedema. These patients should be closely monitored for lymphedema and possible early intervention for the condition.
authors.affiliation: Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Michelle C
authors.initials: MC
authors.lastname: Specht
authors.forename: Cynthia L
authors.initials: CL
authors.lastname: Miller
authors.forename: Melissa N
authors.initials: MN
authors.lastname: Skolny
authors.forename: Lauren S
authors.initials: LS
authors.lastname: Jammallo
authors.forename: Jean
authors.initials: J
authors.lastname: O'Toole
authors.forename: Nora
authors.initials: N
authors.lastname: Horick
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Isakoff
authors.forename: Barbara L
authors.initials: BL
authors.lastname: Smith
authors.forename: Alphonse G
authors.initials: AG
authors.lastname: Taghian
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000009:adverse effects; D001365:Axilla; D015992:Body Mass Index; D001943:Breast Neoplasms / Q000150:complications* / Q000628:therapy; D017024:Chemotherapy, Adjuvant / Q000009:adverse effects*; D003131:Combined Modality Therapy; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008197:Lymph Node Excision / Q000009:adverse effects*; D008209:Lymphedema / Q000175:diagnosis / Q000209:etiology*; D008875:Middle Aged; D020360:Neoadjuvant Therapy / Q000009:adverse effects*; D009364:Neoplasm Recurrence, Local / Q000150:complications* / Q000628:therapy; D009367:Neoplasm Staging; D018365:Neoplasm, Residual / Q000175:diagnosis / Q000209:etiology*; D011379:Prognosis; D011446:Prospective Studies; D012307:Risk Factors; D021701:Sentinel Lymph Node Biopsy