Bone loss in the affected forearm in patients with breast cancer-related lymphedema: a controlled study

  • Secil Pervane VuralEmail author
  • F. Figen Ayhan
  • Burcu Duyur Cakit
  • Atilla Soran
Original Article



We aimed to investigate the association between lymphedema and bone mass density (BMD) of affected and unaffected forearms in patients with breast cancer-related lymphedema (BCRL). We also explored whether there was a relationship between any disability and BMD on the affected side.


We evaluated 111 patients (53.75 ± 9.07) with unilateral lymphedema (group 1) and 61 patients (50.90 ± 12.44) without lymphedema (group 2) after breast cancer surgery. BMD was performed by dual-energy x-ray absorptiometry (DXA) in lumbar spine, femoral neck, and distal forearm on both sides. Functional situation was assessed by the Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire.


The total Z score (p = 0.018), T score (p = 0.005), and BMD value (p = 0.014) were lower in the affected forearm than the unaffected forearm in group 1. There was no difference between the affected or unaffected sides in the total Z score (p = 0.394), T score (p = 0.518), and BMD value (p = 0.629) in group 2. The DXA measurements in terms of the total forearm Z, T scores, and BMD value on the affected side were statistically significantly different between the groups. There was no difference between groups in the femur neck and lumbar total Z and T scores. There was also a positive correlation between the QuickDASH scores and lymphedema stage (r = 0.469, p = 0.001) and the duration without treatment of lymphedema (r = 0.298, p = 0.02) in group 1.


We recommend early diagnosis and treatment of lymphedema for the protection of upper extremity disability and localized osteoporosis in patients with BCRL.


Lymphedema Osteoporosis Local bone loss QuickDASH Quality of life 


Compliance with ethical standards

The corresponding author has full control of all primary data and agrees to allow the journal to review the data if requested.

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    (2013) The diagnosis treatment of peripheral lymphedema: 2016 Consensus document of the International Society of Lymphology. Lymphology 49:170–184Google Scholar
  2. 2.
    Bakar Y, Berdici B, Sahin N, Pala OO (2014) Lymphedema after breast cancer and its treatment. J Breast Health 10:6–14CrossRefGoogle Scholar
  3. 3.
    Shah C, Arthur D, Riutta J, Whitworth P, Vicini FA (2012) Breast-Cancer related lymphedema: a review of procedure-specific incidence rates, clinical assessment aids, treatment paradigms, and risk reduction. Breast J 18(4):357–361CrossRefGoogle Scholar
  4. 4.
    Stubblefield MD, Custodio CM (2006) Upper-extremity pain disorders in breast cancer. Arch Phys Med Rehabil 87(3):96–99CrossRefGoogle Scholar
  5. 5.
    Pierce SM, Recht A, Lingos TI, Abner A, Vicini F, Silver B, Herzog A, Harris JR (1992) Long-term radiation complications following conservative surgery (CS) and radiation therapy (RT) in patients with early stage breast cancer. Int J Radiat Oncol Biol Phys 23(5):915–923CrossRefGoogle Scholar
  6. 6.
    Poniatowski BC, Grimm P, Cohen G (2001) Chemotherapy-induced menopause: a literature review. Cancer Investig 19(6):641–648CrossRefGoogle Scholar
  7. 7.
    Smith IE, Dowsett M (2003) Aromatase inhibitors in breast cancer. N Engl J Med 348(24):2431–2442CrossRefGoogle Scholar
  8. 8.
    Khan M, Khan A (2008) Cancer treatment–related bone loss: a review and synthesis of the literature. Curr Oncol 15(1):30–40CrossRefGoogle Scholar
  9. 9.
    ISL (2009) I. The diagnosis and treatment of peripheral lymphedema 2009 Consensus Document of the International Society of Lymphology Lymphology 42 (2):51–60Google Scholar
  10. 10.
    Sitzja J (1995) Volume measurement in lymphedema treatment: examination of formula. Eur J Cancer Care 4:11–16CrossRefGoogle Scholar
  11. 11.
    Martins DSR, Rezende LF (2014) Assessment of impact of late postoperative physical functional disabilities on quality of life in breast cancer survivors. Tumori 100(1):87–90CrossRefGoogle Scholar
  12. 12.
    Schmitz KH, Ahmed RL, Troxel A, Cheville A, Smith R, Lewis-Grant L, Bryan CJ, Williams-Smith CT, Greene QP (2009) Weight lifting in women with breast-cancer–related lymphedema. N Engl J Med 361(7):664–673CrossRefGoogle Scholar
  13. 13.
    Hill DA, Horick NK, Isaacs C, Domchek SM, Tomlinson GE, Lowery JT, Kinney AY, Berg JS, Edwards KL, Moorman PG, Plon SE, Strong LC, Ziogas A, Griffin CA, Kasten CH, Finkelstein DM (2014) Long-term risk of medical conditions associated with breast cancer treatment. Breast Cancer Res Treat 145(1):233–243CrossRefGoogle Scholar
  14. 14.
    Eastell R, Adams JE, Coleman RE, Howell A, Hannon RA, Cuzick J, Mackey JR, Beckmann MW, Clack G (2008) Effect of anastrozole on bone mineral density: 5-year results from the anastrozole, tamoxifen, alone or in combination trial 18233230. J Clin Oncol 26(7):1051–1057CrossRefGoogle Scholar
  15. 15.
    Winters-Stone KM, Schwartz AL, Hayes SC, Fabian CJ, Campbell KL (2012) A prospective model of care for breast cancer rehabilitation: bone health and arthralgias. Cancer 118(S8):2288–2299CrossRefGoogle Scholar
  16. 16.
    Liu M, Tetsuya T, Yoshiko H (1999) Osteoporosis in hemiplegic stroke patients as studied with dual energy X-ray absorptiometry. Arch Phys Med Rehabil 80:1219–1226CrossRefGoogle Scholar
  17. 17.
    Ramnemark A, Nyberg L, Lorentzon R (1999) Progressive hemi osteoporosis on paretic side and increased bone mineral density in non-paretic arm first year after severe stroke. Osteoporos İnt 9:269–275CrossRefGoogle Scholar
  18. 18.
    Sato Y, Kuno H, Kaji M, Ohshima Y, Asoh T, Oizumi K (1998) Increased bone resorption during the first year after stroke. Stroke 29:1373–1377CrossRefGoogle Scholar
  19. 19.
    Sato Y, Maruoka H, Oizumi K, Kikuyama M (1996) Vitamin D deficiency and osteopenia in the hemiplegic limbs of stroke patients. Stroke 27:2183–2187CrossRefGoogle Scholar
  20. 20.
    Ayman A, Grada MD, Tania J, Philips MD (2017) Lymphedema. J Am Acad Dermatol 77(6):1009–1020CrossRefGoogle Scholar
  21. 21.
    Srivastava RK, Dar HY, Mishra PK (2018) Immunoporosis: immunology of osteoporosis-role of T cells. Front Immunol 5(9):657CrossRefGoogle Scholar
  22. 22.
    Laroche M (2016) Focus on the bone in complex regional pain syndrome type I. Joint Bone Spine 83(6):731CrossRefGoogle Scholar
  23. 23.
    Elefteriou F, Karsenty G (2013) Primer on the metabolic bone diseases and disorders of bone metabolism. In: Clifford jR (ed) Neuronal regulation of bone remodeling, 8th edn. Wiley and son, Hoboken, pp 82–90Google Scholar
  24. 24.
    Ceceli E, Ayhan Ardıc F, Ergun S, Karaoglan B, Yorgancıoglu R (1998) Diagnosis and follow-up of reflex sympathetic dystropy syndrome by dual energy x-ray absorbtiometry. Phys Med 1:7–10Google Scholar
  25. 25.
    Smoot B, Wong J, Cooper B, Wanek L, Topp K, Byl N, Dodd M (2010) Upper extremity impairments in women with or without lymphedema following breast cancer treatment. J Cancer Surviv 4(2):167–178CrossRefGoogle Scholar
  26. 26.
    Dawes DJ, Meterissian S, Goldberg M, Mayo NE (2008) Impact of lymphoedema on arm function and health-related quality of life in women following breast cancer surgery. J Rehabil Med 40:651–658CrossRefGoogle Scholar
  27. 27.
    Cariati M, Bains SK, Grootendorst MR, Suyoi A, Peters AM, Mortimer P, Ellis P, Harries M, van Hemelrijck M, Purushotham AD (2015) Adjuvant taxanes and the development of breast cancer-related arm lymphoedema. Br J Surg 102(9):1071–1078CrossRefGoogle Scholar
  28. 28.
    Deutsch M, Land S, Begovic M, Sharif S (2008) The incidence of arm edema in women with breast cancer randomized on the National Surgical Adjuvant Breast and Bowel Project study B-04 to radical mastectomy versus total mastectomy and radiotherapy versus total mastectomy alone. Int J Radiat Oncol Biol Phys 70(4):1020–1024CrossRefGoogle Scholar
  29. 29.
    Pinto M, Gimigliano F, Tatangelo F, Megna M, Izzo F, Gimigliano R, Iolascon G (2013) Upper limp function and quality of life in breast cancer related lymphedema: a cross-sectional study. Eur J Phys Rehabil Med 49:665–673PubMedGoogle Scholar
  30. 30.
    Bojinovic-Rodic D, Popovic-Petrovic S, Tomic S, Markez S, Zivanic D (2016) Upper extremity function and quality of life in patients with breast cancer related lymphedema. Vojnosanit Pregl 73(9):825–830CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Secil Pervane Vural
    • 1
    Email author
  • F. Figen Ayhan
    • 1
  • Burcu Duyur Cakit
    • 1
  • Atilla Soran
    • 2
  1. 1.Department of Physical Medicine and Rehabilitation, Division of Oncological RehabilitationS.B.U Ankara Training and Research HospitalAnkaraTurkey
  2. 2.Division of Surgical Oncology, Department of Surgery, Magee-Womens Hospital of University of Pittsburgh Medical Center, School of MedicineUniversity of PittsburghPittsburghUSA

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