Nomograms for Predicting the Risk of Arm Lymphedema after Axillary Dissection in Breast Cancer
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Lymphedema (LE) after axillary lymph node dissection (ALND) is a multifactorial, chronic, and disabling condition that currently affects an estimated 4 million people worldwide. Although several risk factors have been described, it is difficult to estimate the risk in individual patients. We therefore developed nomograms based on a large data set.
Clinicopathologic features were collected from a prospective cohort comprising 1,054 women with unilateral breast cancer undergoing ALND as part of their surgical treatment from August 2001 to November 2002. LE was defined as a volume difference of at least 200 ml between arms at 6 months or more after surgery. The cumulative incidence of LE was ascertained by the Kaplan–Meier method, and Cox proportional hazard models were used to predict the risk of developing LE on the basis of the available data at each time point: model 1, preoperatively; model 2, within 6 months from surgery; and model 3, at 6 months or later after surgery.
The 5 year cumulative incidence of LE was 30.3%. Independent risk factors for LE were age, body mass index, ipsilateral arm chemotherapy infusions, level of ALND, location of radiotherapy field, development of postoperative seroma, infection, and early edema. When applied to the validation set, the concordance indices were 0.706, 0.729, and 0.736 for models 1, 2, and 3, respectively.
The proposed nomograms can help physicians and patients predict the 5 year probability of LE after ALND for breast cancer. Free online versions of the nomograms are available at http://www.lymphedemarisk.com/.
KeywordsBreast Cancer Sentinel Lymph Node Sentinel Lymph Node Biopsy Lymphedema Axillary Lymph Node Dissection
The authors would like to express their deepest gratitude to all patients, surgeons, and physical therapists at HCIII/INCA, Rio de Janeiro, Brazil; and to Dr. Kimberly Van Zee of Memorial Sloan-Kettering Cancer Center, NY; to Dr. Mauro Figueiredo Andrade of Faculdade de Medicina da Universidade de São Paulo, Brazil, for their insights, encouragement, and constructive criticism; to Dr. C. Greg Hagerty for his assistance in the computer application; and to Dr. Everardo Saad for proofreading. Supported by Fundação Carlos Chagas Filho de Amparo à Pesquisa do Estado do Rio de Janeiro (FAPERJ), Postdoctoral grant E-26/100.851/2007, Conselho Nacional de Pesquisas e Desenvolvimento Tecnológico (CNPq), and Escola Nacional de Saúde Púbica, FIOCRUZ.
- 1.Ferlay J, Bray F, Pisani P, Parkin DM. GLOBOCAN 2008, Cancer incidence and mortality worldwide. IARC CancerBase No. 10. Lyon, France: International Agency for Research on Cancer; 2010. http://globocan.iarc.fr.
- 2.American Cancer Society. Cancer facts and figures, 2010. Atlanta: American Cancer Society; 2010.Google Scholar
- 3.Surveillance, Epidemiology, and End Results. Cancer of the breast (invasive)—estimated United States cancer prevalence counts on January 1, 2007, by race/ethnicity, sex and years since diagnosis (table 4.25). SEER Cancer Statistics Review, 1975–2007. http://seer.cancer.gov/csr/1975_2007/browse_csr.php?section=4&page=sect_04_table.25.html.
- 4.International Data Base (IDB)—World population summary. US Census Bureau, Population Division, December 11, 2010. http://www.census.gov/ipc/www/idb/worldpopinfo.php.
- 22.Almeida AM, Prado MAS, Guidorizzi LLF, Rossini FP. Mulheres com câncer de mama: estudo de morbidade. Acta Oncol Bras. 2002;22:263–9.Google Scholar
- 39.Bergmann A. Diagnóstico de linfedema: análise dos métodos empregados na avaliação do membro superior após linfadenectomia axilar para tratamento do câncer de mama. Rev Bras Cancerol. 2004;50:311–20.Google Scholar
- 40.Bergmann A, Koifman RJ, Ribeiro MJP, Mattos IE. Upper limb lymphedema following breast cancer surgery: prevalence and associated factors. Lymphology. 2007;40(Suppl.):96–106.Google Scholar
- 41.Bergmann A. Incidência e fatores de risco do linfedema após tratamento cirúrgico para câncer de mama: Estudo de uma coorte hospitalar. Rio de Janiero: Escola Nacional de Saúde Pública, Fundação Oswaldo Cruz; 2005.Google Scholar
- 51.Clark GM. Prognostic and Predictive Factors. In: Harris JR, Lippman ME, Morrow M, Osborne CK, editors. Diseases of the breast. Philadelphia: Lippincott Williams & Wilkins; 1996. p. 461–85.Google Scholar
- 61.Mathers C, Fat DM, Boerma JT, World Health Organization. The global burden of disease 2004 update. Geneva: World Health Organization; 2008.Google Scholar
- 63.Giuliano AE, McCall L, Beitsch P, et al. Locoregional recurrence after sentinel lymph node dissection with or without axillary dissection in patients with sentinel lymph node metastases: the American College of Surgeons Oncology Group Z0011 randomized trial. Ann Surg. 2010;252:426–32.PubMedGoogle Scholar
- 66.National Comprehensive Cancer Network (NCCN). Clinical practice guidelines in oncology, version 2, 2011. http://www.nccn.org/.