Postmastectomy radiotherapy (PMRT) has proven benefits for certain patients with breast cancer; however, one of its complications is lymphedema. This study examines the incidence of and risk factors associated with lymphedema secondary to PMRT.
The charts of patients treated with mastectomy at Roswell Park Cancer Institute between January 1, 1995, and April 20, 2001, who received PMRT were reviewed. Univariate analysis of patient, disease, and treatment variables was conducted. Multivariate analysis was performed on variables found to be significant in univariate analysis.
One hundred five patients received PMRT. The incidence of lymphedema was 27%. Patient age, body mass index, disease stage, positive lymph nodes, nodes resected, postoperative infection, duration of drainage, chemotherapy, and hormonal therapy were not associated with lymphedema. Total dose (P = .032), posterior axillary boost (P = .047), overlap technique (P = .037), radiotherapy before 1999 (P = .028), and radiotherapy at Roswell Park Cancer Institute (P = .028) were significantly associated with lymphedema. Increased lymphedema was noted with supraclavicular, internal mammary, mastectomy scar boost, and chest wall tangential photon beam radiation, but the associations were not statistically significant.
The high incidence and debilitating effects of lymphedema must be weighed against the benefits of PMRT. Efforts to prevent lymphedema should be emphasized.
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Recht A, Edge S, Solin LJ, et al. Postmastectomy radiotherapy: clinical practice guidelines of the American Society of Clinical Oncology. J Clin Oncol 2001;19:1539–69.
Overgaard M, Hansen PS, Overgaard J, et al. Postoperative radiotherapy in high-risk premenopausal women with breast cancer who receive adjuvant chemotherapy. Danish Breast Cancer Cooperative Group 82b Trial. N Engl J Med 1997;337:949–55.
Ragaz J, Jackson S, Le N, et al. Postmastectomy radiation outcome in node positive breast cancer patients among N1–3 versus N4+ subsets: impact of extracapsular spread. Update of British Columbia Randomized Trial (abstract). Proc Am Soc Clin Oncol 1999;274:73.
Overgaard M, Jensen M, Overgaard J, et al. Postoperative radiotherapy in high-risk postmenopausal breast-cancer patients given adjuvant tamoxifen: Danish Breast Cancer Cooperative Group DBCG 82c randomised trial. Lancet 1999;353:1641–8.
Harris JR, Halpin-Murphy P, McNeese M, Mendenhall NP, Morrow M, Robert NJ. Consensus statement on postmastectomy radiation therapy. Int J Radiat Oncol Biol Phys 1999;44:989–90.
Olsen NK, Pfeiffer P, Johannsen L, Schroder H, Rose C. Radiation-induced brachial plexopathy: neurological follow-up in 161 recurrence-free breast cancer patients. Int J Radiat Oncol Biol Phys 1993;26:43–9.
Cuzick J, Stewart H, Rutqvist L, et al. Cause-specific mortality in long-term survivors of breast cancer who participated in trials of radiotherapy. J Clin Oncol 1994;12:447–53.
Tasmuth T, von Smitten K, Hietanen P, Kataja M, Kalso E. Pain and other symptoms after different treatment modalities of breast cancer. Ann Oncol 1995;6:453–9.
Overgaard M, Bentzen SM, Christensen JJ, Madsen EH. The value of the NSD formula in equation of acute and late radiation complications in normal tissue following 2 and 5 fractions per week in breast cancer patients treated with postmastectomy irradiation. Radiother Oncol 1987;9:1–11.
Overgaard M, Christensen JJ, Johansen H, et al. Postmastectomy irradiation in high-risk breast cancer patients. Present status of the Danish Breast Cancer Cooperative Group trials. Acta Oncol 1988;27:707–14.
Swedborg I, Wallgren A. The effect of pre- and postmastectomy radiotherapy on the degree of edema, shoulder-joint mobility, and gripping force. Cancer 1981;47:877–81.
Segerstrom K, Bjerle P, Nystrom A. Importance of time in assessing arm and hand function after treatment of breast cancer. Scand J Plast Reconstr Surg Hand Surg 1991;25:241–4.
Hojris I, Andersen J, Overgaard M, Overgaard J. Late treatment-related morbidity in breast cancer patients randomized to postmastectomy radiotherapy and systemic treatment versus systemic treatment alone. Acta Oncol 2000;39:355–72.
Ryttov N, Holm NV, Qvist N, Blichert-Toft M. Influence of adjuvant irradiation on the development of late arm lymphedema and impaired shoulder mobility after mastectomy for carcinoma of the breast. Acta Oncol 1988;27:667–70.
Host H, Brennhovd IO, Loe M. Postoperative radiotherapy in breast cancer—long-term results from the Oslo study. Int J Radiat Oncol Biol Phys 1986;12:727–32.
Jones JM, Ribeiro GG. Mortality patterns over 34 years of breast cancer patients in a clinical trial of post-operative radiotherapy. Clin Radiol 1989;40:204–8.
Haybittle JL, Brinkley D, Houghton J, A’Hern RP, Baum M. Postoperative radiotherapy and late mortality: evidence from the Cancer Research Campaign trial for early breast cancer. BMJ 1989;298:1611–4.
Rutqvist LE, Lax I, Fornander T, Johansson H. Cardiovascular mortality in a randomized trial of adjuvant radiation therapy versus surgery alone in primary breast cancer. Int J Radiat Oncol Biol Phys 1992;22:887–96.
Tracy GD, Reeve TS, Fitzsimons E, Rundle FF. Observations on the swollen arm after radical mastectomy. Aust N Z J Surg 1961;30:204–8.
Newman ML, Brennan M, Passik S. Lymphedema complicated by pain and psychological distress: a case with complex treatment needs. J Pain Symptom Manage 1996;12:376–9.
Tobin M, Lacey HJ, Meyer L, Mortimer PS. The psychological morbidity of breast cancer-related arm swelling. Psychological morbidity of lymphoedema. Cancer 1993;72:3248–52.
Carter BJ. Women’s experiences of lymphedema. Oncol Nurs Forum 1997;24:875–82.
Velanovich V, Szymanski W. Quality of life of breast cancer patients with lymphedema. Am J Surg 1999; 177: 184–7. discussion 188
Passik S, Newman M, Brennan M, Holland J. Psychiatric consultation for women undergoing rehabilitation for upper-extremity lymphedema following breast cancer treatment. J Pain Symptom Manage 1993;8:226–33.
Passik SD, McDonald MV. Psychosocial aspects of upper extremity lymphedema in women treated for breast carcinoma. Cancer 1998; 83(12 Suppl American): 2817–20.
Passik SD, Newman M, Brennan M. Predictors of psychological distress, sexual dysfunction and physical functioning among women with upper extremity lymphedema related to breast cancer. Psycho-Oncology 1995;4:255–63.
Kwan W, Jackson J, Weir LM, Dingee C, McGregor G, Olivotto IA. Chronic arm morbidity after curative breast cancer treatment: prevalence and impact on quality of life. J Clin Oncol 2002;20:4242–8.
Karcher KH. Clinical aspects and therapy of angioplastic sarcoma of the edamatous arm following mastectomy (Stewart-Treves syndrome) (in German). Strahlentherapie 1966;131:255–63.
Mortimer P, Regnard C. Lymphostatic disorders. BMJ (Clin Res Ed) 1986;293:347–8.
Meissner HJ. Das Stewart-Treves-Syndrom. Akuelle Chir 1977;12:25.
Zschoch H. Stewart-Treves syndrome (in German). Zentralbl Chir 1975;100:868–72.
Mortimer PS. The pathophysiology of lymphedema. Cancer 1998;83:2798–802.
Velez-Garcia E, Carpenter JT, Moore M, et al. Postsurgical adjuvant chemotherapy with or without radiotherapy in women with breast cancer and positive axillary nodes: a South-Eastern Cancer Study Group (SEG) Trial. Eur J Cancer 1992;28A:1833–7.
Tennvall-Nittby L, Tengrup I, Landberg T. The total incidence of loco-regional recurrence in a randomized trial of breast cancer TNM stage II. The South Sweden Breast Cancer Trial. Acta Oncol 1993;32:641–6.
Ragaz J, Jackson SM, Le N, et al. Adjuvant radiotherapy and chemotherapy in node-positive premenopausal women with breast cancer. N Engl J Med 1997;337:956–62.
McArdle CS, Crawford D, Dykes EH, et al. Adjuvant radiotherapy and chemotherapy in breast cancer. Br J Surg 1986;73:264–6.
Ahmann DL, O’Fallon JR, Scanlon PW, et al. A preliminary assessment of factors associated with recurrent disease in a surgical adjuvant clinical trial for patients with breast cancer with special emphasis on the aggressiveness of therapy. Am J Clin Oncol 1982;5:371–81.
Griem KL, Henderson IC, Gelman R, et al. The 5-year results of a randomized trial of adjuvant radiation therapy after chemotherapy in breast cancer patients treated with mastectomy. J Clin Oncol 1987;5:1546–55.
Carlson RW, Edge S, Theriault RL. NCCN: breast cancer. Cancer Control 2001; 8(6 Suppl 2): 54–61.
Blomqvist C, Tiusanen K, Elomaa I, et al. The combination of radiotherapy, adjuvant chemotherapy (cyclophosphamide-doxorubicin-ftorafur) and tamoxifen in stage II breast cancer. Long-term follow-up results of a randomised trial. Br J Cancer 1992;66:1171–6.
Klefstrom P, Grohn P, Heinonen E, et al. Adjuvant postoperative radiotherapy, chemotherapy, and immunotherapy in stage III breast cancer. II. 5-year results and influence of levamisole. Cancer 1987;60:936–42.
Schunemann H, Willich N. Lymphoedema of the arm after primary treatment of breast cancer. Anticancer Res 1998;18:2235–6.
Pezner RD, Lipsett JA, Forell, et al. The reverse hockey stick technique: postmastectomy radiation therapy for breast cancer patients with locally advanced tumor presentation or extensive loco-regional recurrence. Int J Radiat Oncol Biol Phys 1989;17:191–7.
Ljungdahl Brismar, I. Postoperative lymphoedema after treatment of breast cancer. Acta Chir Scand 1983;149:687–9.
Gregl A, Heitmann D, Krack U. Frequency, clinical and radiological symptomatology and therapy of the arm oedema combined with mastocarcinoma (author’s transl) (in German). Strahlentherapie 1978;154:482–8.
Gregl A, Poppe H, Pohls H, Kienle J, Schwartz T, Stelzner J. Occurrence, pathogenesis and clinical symptoms of arm edema in breast carcinoma (in German). Strahlentherapie 1967;133:499–515.
Johansson S, Svensson H, Denekamp J. Dose response and latency for radiation-induced fibrosis, edema, and neuropathy in breast cancer patients. Int J Radiat Oncol Biol Phys 2002;52:1207–19.
Shikama N, Oguchi M, Sone S, et al. Radiotherapy following mastectomy: indication and contraindication of chest wall irradiation. Int J Radiat Oncol Biol Phys 1999;44:991–6.
Segerstrom K, Bjerle P, Graffman S, Nystrom A. Factors that influence the incidence of brachial oedema after treatment of breast cancer. Scand J Plast Reconstr Surg Hand Surg 1992;26:223–7.
Kissin MW, Querci della Rovere G, Easton D, Westbury G. Risk of lymphoedema following the treatment of breast cancer. Br J Surg 1986;73:580–4.
Keramopoulos A, Tsionou C, Minaretzis D, Michalas S, Aravantinos D. Arm morbidity following treatment of breast cancer with total axillary dissection: a multivariated approach. Oncology 1993;50:445–9.
Werner RS, Petrek, McCormick, J, et al. Arm edema in conservatively managed breast cancer: obesity is a major predictive factor. Radiology 1991;180:177–84.
Pezner RD, Patterson MP, Hill LR, et al. Arm lymphedema in patients treated conservatively for breast cancer: relationship to patient age and axillary node dissection technique. Int J Radiat Oncol Biol Phys 1986;12:2079–83.
Kiel KD, Rademacker AW. Early-stage breast cancer: arm edema after wide excision and breast irradiation. Radiology 1996;198:279–83.
Crowe, Jr JP, Gordon NH, Antunez AR, Shenk RR, Hubay CA, Shuck JM. Local-regional breast cancer recurrence following mastectomy. Arch Surg 1991;126:429–32.
Ballo MT, Strom EA, Prost H, et al. Local-regional control of recurrent breast carcinoma after mastectomy: does hyperfractionated accelerated radiotherapy improve local control?. Int J Radiat Oncol Biol Phys 1999;44:105–12.
Bedwinek JM, Lee J, Ocwieza, Fineberg, M. Prognostic indicators in patients with isolated local-regional recurrence of breast cancer. Cancer 1981;47:2232–5.
Schwaibold F, Fowble BL, Solin LJ, Schultz DJ, Goodman RL. The results of radiation therapy for isolated local regional recurrence after mastectomy. Int J Radiat Oncol Biol Phys 1991;21:299–310.
Andry G, Suciu S, Vico P, et al. Locoregional recurrences after 649 modified radical mastectomies: incidence and significance. Eur J Surg Oncol 1989;15:476–85.
Toonkel LM, Fix I, Jacobson LH, Wallach C. The significance of local recurrence of carcinoma of the breast. Int J Radiat Oncol Biol Phys 1983;9:33–9.
Gray, Fowble, R, Gilchrist K, Goodman RL, Taylor S, Tormey DC. Identification of a subgroup of patients with breast cancer and histologically positive axillary nodes receiving adjuvant chemotherapy who may benefit from postoperative radiotherapy. J Clin Oncol 1988;6:1107–17.
Strom EA, McNeese MD. Postmastectomy irradiation: rationale for treatment field selection. Semin Radiat Oncol 1999;9:247–53.
Arriagada R, Rutqvist LE, Mattsson A, Kramar A, Rotstein S. Adequate locoregional treatment for early breast cancer may prevent secondary dissemination. J Clin Oncol 1995;13:2869–78.
Grohn P, Heinonen E, Klefstrom P, Tarkkanen J. Adjuvant postoperative radiotherapy, chemotherapy, and immunotherapy in stage III breast cancer. Cancer 1984;54:670–4.
Auquier A, Rutqvist LE, Host H, Rotstein S, Arriagada R. Post-mastectomy megavoltage radiotherapy: the Oslo and Stockholm trials. Eur J Cancer 1992;28:433–7.
Danforth DN, Jr, Findlay PA, McDonald HD, et al. Complete axillary lymph node dissection for stage I-II carcinoma of the breast. J Clin Oncol 1986;4:655–62.
Pigott J, Nichols R, Maddox WA, Balch CM. Metastases to the upper levels of the axillary nodes in carcinoma of the breast and its implications for nodal sampling procedures. Surg Gynecol Obstet 1984;158:255–9.
Rosen PP, Lesser ML, Kinne DW, Beattie EJ. Discontinuous or “skip” metastases in breast carcinoma. Analysis of 1228 axillary dissections. Ann Surg 1983;197:276–83.
Veronesi U, Rilke F, Luini A, et al. Distribution of axillary node metastases by level of invasion. An analysis of 539 cases. Cancer 1987;59:682–7.
Recht A, Pierce SM, Abner A, et al. Regional nodal failure after conservative surgery and radiotherapy for early-stage breast carcinoma. J Clin Oncol 1991;9:988–96.
Halverson KJ, Taylor ME, Perez CA, et al. Regional nodal management and patterns of failure following conservative surgery and radiation therapy for stage I and II breast cancer. Int J Radiat Oncol Biol Phys 1993;26:593–9.
Vicini FA, Horwitz EM, Lacerna MD, et al. The role of regional nodal irradiation in the management of patients with early-stage breast cancer treated with breast-conserving therapy. Int J Radiat Oncol Biol Phys 1997;39:1069–76.
Mehta K, Haffty BG. Long-term outcome in patients with four or more positive lymph nodes treated with conservative surgery and radiation therapy. Int J Radiat Oncol Biol Phys 1996;35:679–85.
Urban JA, Marjani MA. Significance of internal mammary lymph node metastases in breast cancer. Am J Roentgenol Radium Ther Nucl Med 1971;111:130–6.
Bucalossi P, Veronesi U, Zingo L, Cantu C. Enlarged mastectomy for breast cancer. Review of 1,213 cases. Am J Roentgenol Radium Ther Nucl Med 1971;111:119–22.
Handley RS. Carcinoma of the breast. Ann R Coll Surg Engl 1975;57:59–66.
Li KY. An analysis of 1,242 cases of extended radical mastectomy. Breast 1984;10:10–9.
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Hinrichs, C.S., Watroba, N.L., Rezaishiraz, H. et al. Lymphedema Secondary to Postmastectomy Radiation: Incidence and Risk Factors. Ann Surg Oncol 11, 573 (2004). https://doi.org/10.1245/ASO.2004.04.017
- Postmastectomy radiation
- Risk factors
- Breast neoplasms