title: Defining a threshold for intervention in breast cancer-related lymphedema: what level of arm volume increase predicts progression?
abstract: The purpose of this study is to evaluate arm volume measurements and clinico-pathologic characteristics of breast cancer patients to define a threshold for intervention in breast cancer-related lymphedema. We prospectively performed arm volume measurements on breast cancer patients using a Perometer. Arm measurements were performed pre- and post-operatively, and change in arm volume was quantified using a relative volume change (RVC) equation. Patient and treatment risk factors were evaluated. Cox proportional hazards models with time-dependent covariates for RVC were used to evaluate whether RVC elevations of ≥3 to <5 % or ≥5 to <10 % occurring ≤3 months or >3 months after surgery were associated with progression to ≥10 % RVC. 1,173 patients met eligibility criteria with a median of 27 months post-operative follow-up. The cumulative incidence of ≥10 % RVC at 24 months was 5.26 % (95 % CI 4.01-6.88 %). By multivariable analysis, a measurement of ≥5 to <10 % RVC occurring >3 months after surgery was significantly associated with an increased risk of progression to ≥10 % RVC (HR 2.97, p < 0.0001), but a measurement of ≥3 to <5 % RVC during the same time period was not statistically significantly associated (HR 1.55, p = 0.10). Other significant risk factors included a measurement ≤3 months after surgery with RVC of ≥3 to <5 % (p = 0.007), ≥5 to <10 % (p < 0.0001), or ≥10 % (p = 0.023), axillary lymph node dissection (ALND) (p < 0.0001), and higher BMI at diagnosis (p = 0.0028). Type of breast surgery, age, number of positive or number of lymph nodes removed, nodal radiation, chemotherapy, and hormonal therapy were not significant (p > 0.05). Breast cancer patients who experience a relative arm volume increase of ≥3 to <5 % occurring >3 months after surgery do not have a statistically significant increase in risk of progression to ≥10 %, a common lymphedema criterion. Our data support utilization of a ≥5 to <10 % threshold for close monitoring or intervention, warranting further assessment. Additional risk factors for progression to ≥10 % include ALND, higher BMI, and post-operative arm volume elevation.
authors.affiliation: Division of Surgical Oncology, Massachusetts General Hospital, 100 Blossom Street, Boston, MA 02114, USA.
authors.forename: Michelle C
authors.initials: MC
authors.lastname: Specht
authors.forename: Cynthia L
authors.initials: CL
authors.lastname: Miller
authors.forename: Tara A
authors.initials: TA
authors.lastname: Russell
authors.forename: Nora
authors.initials: N
authors.lastname: Horick
authors.forename: Melissa N
authors.initials: MN
authors.lastname: Skolny
authors.forename: Jean A
authors.initials: JA
authors.lastname: O'Toole
authors.forename: Lauren S
authors.initials: LS
authors.lastname: Jammallo
authors.forename: Andrzej
authors.initials: A
authors.lastname: Niemierko
authors.forename: Betro T
authors.initials: BT
authors.lastname: Sadek
authors.forename: Mina N
authors.initials: MN
authors.lastname: Shenouda
authors.forename: Dianne M
authors.initials: DM
authors.lastname: Finkelstein
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; D001132:Arm / Q000503:physiopathology; D001943:Breast Neoplasms / Q000150:complications* / Q000473:pathology / Q000601:surgery* / Q000628:therapy; D018450:Disease Progression; D005260:Female; D006801:Humans; D008197:Lymph Node Excision / Q000009:adverse effects; D008209:Lymphedema / Q000453:epidemiology / Q000209:etiology* / Q000473:pathology; D008408:Mastectomy / Q000009:adverse effects; D008875:Middle Aged; D015999:Multivariate Analysis; D011184:Postoperative Period; D016016:Proportional Hazards Models; D011446:Prospective Studies; D013997:Time Factors; D055815:Young Adult
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