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Considerations for Clinicians in the Diagnosis, Prevention, and Treatment of Breast Cancer-Related Lymphedema, Recommendations from an Expert Panel: Part 2: Preventive and Therapeutic Options

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References

  1. McLaughlin SA, et al. Trends in risk reduction practices for the prevention of lymphedema in the first 12 months after breast cancer surgery. J Am Coll Surg. 2013;216(3):380–9.

  2. McLaughlin SA, et al. Prevalence of lymphedema in women with breast cancer 5 years after sentinel lymph node biopsy or axillary dissection: patient perceptions and precautionary behaviors. J Clin Oncol. 2008;26:5220–6.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Showalter SL, et al. Lifestyle risk factors associated with arm swelling among women with breast cancer. Ann Surg Oncol. 2013;20:842–9.

    Article  PubMed  Google Scholar 

  4. Kilbreath SL, et al. Risk factors for lymphoedema in women with breast cancer: a large prospective cohort. Breast. 2016;28:29–36.

    CAS  Article  PubMed  Google Scholar 

  5. Ferguson, CM, et al. Impact of ipsilateral blood draws, injections, blood pressure measurements, and air travel on the risk of lymphedema for patients treated for breast cancer. J Clin Oncol. 2016;34:691–8.

    Article  PubMed  Google Scholar 

  6. The diagnosis and treatment of peripheral lymphedema: 2016 consensus document of the International Society of Lymphology. Lymphology. 2016;49:170–84.

    Google Scholar 

  7. Gerber LH. Cancer rehabilitation into the future. Cancer. 2001;92(4 Suppl):975–9.

    CAS  Article  PubMed  Google Scholar 

  8. Pinto BM, Maruyama NC. Exercise in the rehabilitation of breast cancer survivors. Psychooncology. 1999;8:191–206.

    CAS  Article  PubMed  Google Scholar 

  9. Pinto BM, et al. Psychological and fitness changes associated with exercise participation among women with breast cancer. Psychooncology. 2003;12:118–26.

    Article  PubMed  Google Scholar 

  10. Rock CL, Demark-Wahnefried W. Can lifestyle modification increase survival in women diagnosed with breast cancer? J Nutr. 2002;132(11 Suppl):3504S–7S.

    CAS  PubMed  Google Scholar 

  11. Schmitz KH, et al. Weight-lifting in women with breast cancer-related lymphedema. N Engl J Med. 2009;361:664–73.

    CAS  Article  PubMed  Google Scholar 

  12. Loudon A, et al. Yoga management of breast cancer-related lymphoedema: a randomised controlled pilot-trial. BMC Complement Alt Med. 2014;14:214.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Di Blasio A, et al. Physical exercises for breast cancer survivors: effects of 10 weeks of training on upper limb circumferences. J Phys Ther Sci. 2016;28:2778–84.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Courneya KS, et al. Effects of aerobic and resistance exercise in breast cancer patients receiving adjuvant chemotherapy: a multicenter randomized controlled trial. J Clin Oncol. 2007;25:4396–404.

    Article  PubMed  Google Scholar 

  15. Hayes SC, Reul-Hirche H, Turner J. Exercise and secondary lymphedema: safety, potential benefits, and research issues. Med Sci Sports Exer. 2009;41:483–9.

    Article  PubMed  Google Scholar 

  16. Portela AL, et al. Feasibility of an exercise program for Puerto Rican women who are breast cancer survivors. Rehab Oncol. 2008;26:20–31.

    PubMed  PubMed Central  Google Scholar 

  17. Exercise for Lymphedema Patients (Internet). National Lymphedema Network, Berkeley, CA. http://www.lymphnet.org/pdfDocs/position.papers/Exercise.pdf (2011). Accessed 6 Feb 2017.

  18. Lymphedema (Internet). American Cancer Society, Atlanta, GA. https://www.cancer.org/treatment/treatments-and-side-effects/physical-side-effects/lymphedema.html (2017). Accessed 6 Feb 2017

  19. Lymphedema (Internet). Susan G. Komen, Dallas, TX (2017). Accessed 6 February 2017.

  20. National Comprehensive Cancer Network (NCCN) Guideline Version 2.2016. http://www.nccn.org/professionals/physician_gls/pdf/breast-screening.pdf (2016). Accessed 23 Jan 2017

  21. Brown JC, Troxel AB, Schmitz KH. Safety of weightlifting among women with or at risk for breast cancer-related lymphedema: musculoskeletal injuries and health care use in a weightlifting rehabilitation trial. Oncologist. 2012;17:1120–8.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Ahmed M, et al. Systematic review of axillary reverse mapping in breast cancer. Br J Surg. 2016;103:170–8.

    CAS  Article  PubMed  Google Scholar 

  23. Beek MA, et al. Axillary reverse mapping in axillary surgery for breast cancer: an update of the current status. Breast Cancer Res Treat. 2016;158:421–32.

    Article  PubMed  Google Scholar 

  24. Boneti C, et al. Axillary reverse mapping (ARM): initial results of phase II trial in preventing lymphedema after lymphadenectomy. Minerva Ginecol. 2012;64:421–30.

    CAS  PubMed  Google Scholar 

  25. Boneti C, et al. Scientific Impact Award: axillary reverse mapping (ARM) to identify and protect lymphatics draining the arm during axillary lymphadenectomy. Am J Surg. 2009;198:482–7.

    Article  PubMed  Google Scholar 

  26. Gebruers N, Tjalma WA. Clinical feasibility of axillary reverse mapping and its influence on breast cancer-related lymphedema: a systematic review. Eur J Obstet Gynecol Reprod Biol. 2016;200:117–22.

    Article  PubMed  Google Scholar 

  27. Han C, et al. The feasibility and oncological safety of axillary reverse mapping in patients with breast cancer: a systematic review and meta-analysis of prospective studies. PloS One. 2016;11:e0150285.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Noguchi M, et al. Feasibility study of axillary reverse mapping for patients with clinically node-negative breast cancer. Eur J Surg Oncol. 2016;42:650–6.

    CAS  Article  PubMed  Google Scholar 

  29. Ochoa D, et al. Axillary reverse mapping: five-year experience. Surgery. 2014;156:1261–8.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Tummel E, et al. Does axillary reverse mapping prevent lymphedema after lymphadenectomy? Ann Surg. 2017;265:987–92.

    Article  PubMed  Google Scholar 

  31. Yue T, et al. A prospective study to assess the feasibility of axillary reverse mapping and evaluate its effect on preventing lymphedema in breast cancer patients. Clin Breast Cancer. 2015;15:301–6.

    Article  PubMed  Google Scholar 

  32. Boccardo F, et al. Lymphedema microsurgical preventive healing approach: a new technique for primary prevention of arm lymphedema after mastectomy. Ann Surg Oncol. 2009;16:703–8.

    Article  PubMed  Google Scholar 

  33. Boccardo FM, et al. Surgical prevention of arm lymphedema after breast cancer treatment. Ann Surg Oncol. 2011;18:2500–5.

    Article  PubMed  Google Scholar 

  34. Boccardo F, et al. Lymphatic microsurgical preventing healing approach (LYMPHA) for primary surgical prevention of breast cancer-related lymphedema: over 4 years follow-up. Microsurgery. 2014;34:421–4.

    Article  PubMed  Google Scholar 

  35. Feldman S, et al. Single-institution experience with lymphatic microsurgical preventive healing approach (LYMPHA) for the primary prevention of lymphedema. Ann Surg Oncol. 2015;22:3296–301.

    Article  PubMed  Google Scholar 

  36. Gomberawalla A, VJ, Borden B, Rohde C, Ascherman J, Taback B, et al. Lymphatic microsurgical preventive healing approach (LYMPHA) for the primary prevention of lymphedema. In: Poster presentation 39th Annual San Antonio Breast Cancer Symposium P2-01-14; 2016.

  37. Position Statement of the National Lymphedema Network. The diagnosis and treatment of lymphedema, NLN Medical Advisory Committee 2011. http://www.lymphnet.org/pdfDocs/nlntreatment.pdf. Accessed 15 Feb 2017.

  38. Szolnoky G, Dobozy A, Kemeny L. Towards an effective management of chronic lymphedema. Clin Dermatol. 2014;32:685–91.

    Article  PubMed  Google Scholar 

  39. Wanchai A, Armer JM, Stewart BR, Lasinski BB Breast cancer-related lymphedema: a literature review for clinical practice. Int J Nurs Sci. 2016;3:202–7.

    Google Scholar 

  40. Randheer S, et al. Comprehensive decongestive therapy in postmastectomy lymphedema: an Indian perspective. Indian J Cancer. 2011;48:397–402.

    CAS  Article  PubMed  Google Scholar 

  41. Position Statement of the National Lymphedema Network. Lymphedema risk reduction practices 2012. http://www.lymphnet.org/pdfDocs/nlnriskreduction.pdf (2017). Accessed 15 February 15 2017.

  42. Smile TD, et al. A review of treatment for breast cancer-related lymphedema: paradigms for clinical practice. Am J Clin Oncol. 2016. DOI: 10.1097/COC.0000000000000355

    PubMed  Google Scholar 

  43. Lasinski BB, et al. A systematic review of the evidence for complete decongestive therapy in the treatment of lymphedema from 2004 to 2011. PM R J Injury Function Rehabil. 2012;4:580–601.

    Google Scholar 

  44. Feldman JL, et al. Intermittent pneumatic compression therapy: a systematic review. Lymphology. 2012;45:13–25.

    CAS  PubMed  Google Scholar 

  45. Rodrick JR, et al. Complementary, alternative, and other noncomplete decongestive therapy treatment methods in the management of lymphedema: a systematic search and review. PM R J Injury Function Rehabil. 2014;6:250–74; quiz 274

    Google Scholar 

  46. Masia J, Pons G, Nardulli ML. Combined surgical treatment in breast cancer-related lymphedema. J Reconstr Microsurg. 2016;32:16–27.

    Article  PubMed  Google Scholar 

  47. Feldman MG, et al. Lymphangiographic studies in obstructive lymphedema of the upper extremity. Surgery. 1966;59:935–43.

    CAS  PubMed  Google Scholar 

  48. Yoo JN, et al. Validity of quantitative lymphoscintigraphy as a lymphedema assessment tool for patients with breast cancer. Ann Rehabil Med. 2015;39:931–40.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Hwang JH, et al. Lymphscintigraphy predicts response to complex physical therapy in patients with early stage extremity lymphedema. Lymphology. 2007;40:172–6.

    CAS  PubMed  Google Scholar 

  50. Stanton AW, et al. Forearm blood flow measured by venous occlusion plethysmography in healthy subjects and in women with postmastectomy oedema. Vasc Med. 1998;3:3–8.

    CAS  Article  PubMed  Google Scholar 

  51. Mihara M, et al. Indocyanine green (ICG) lymphography is superior to lymphoscintigraphy for diagnostic imaging of early lymphedema of the upper limbs. PloS One. 2012;7:e38182.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  52. Vaughan BF. CT of swollen legs. Clin Radiol. 1990;41:24–30.

    CAS  Article  PubMed  Google Scholar 

  53. Boccardo F, et al. Lymphatic microsurgery to treat lymphedema: techniques and indications for better results. Ann Plast Surg. 2013;71:191–5.

    CAS  Article  PubMed  Google Scholar 

  54. Mihara M, et al. Upper-limb lymphedema treated aesthetically with lymphaticovenous anastomosis using indocyanine green lymphography and noncontact vein visualization. J Reconstr Microsurg. 2012;28:327–32.

    Article  PubMed  Google Scholar 

  55. Becker C. Autologous lymph node transfers. J Reconstr Microsurg. 2016;32:28–33.

    CAS  PubMed  Google Scholar 

  56. Baumeister RG, et al. Microsurgical lymphatic vessel transplantation. J Reconstr Microsurg. 2016;32:34–41.

    PubMed  Google Scholar 

  57. Campisi C, Boccardo F. Microsurgical techniques for lymphedema treatment: derivative lymphatic-venous microsurgery. World J Surg. 2004;28:609–13.

    Article  PubMed  Google Scholar 

  58. Maclellan RA, Greene AK. Lymphedema. Semin Pediatr Surg. 2014;23:191–7.

    Article  PubMed  Google Scholar 

  59. Loh CY, et al. The 5th World Symposium for Lymphedema Surgery: recent updates in lymphedema surgery and setting up of a global knowledge exchange platform. J Surg Oncol. 2017;115:6–12.

    Article  PubMed  Google Scholar 

  60. Yamamoto T, et al. Indocyanine green-enhanced lymphography for upper extremity lymphedema: a novel severity staging system using dermal backflow patterns. Plast Reconstr Surg. 2011;128:941–7.

    CAS  Article  PubMed  Google Scholar 

  61. Yamamoto T, et al. Characteristic indocyanine green lymphography findings in lower extremity lymphedema: the generation of a novel lymphedema severity staging system using dermal backflow patterns. Plast Reconstr Surg. 2011;127:1979–86.

    CAS  Article  PubMed  Google Scholar 

  62. Becker C, et al. Postmastectomy lymphedema: long-term results following microsurgical lymph node transplantation. Ann Surg. 2006;243:313–5.

    Article  PubMed  PubMed Central  Google Scholar 

  63. Tobbia, D, et al. Lymphedema development and lymphatic function following lymph node excision in sheep. J Vasc Res. 2009;46:426–34.

    Article  PubMed  Google Scholar 

  64. Slavin SA, et al. Return of lymphatic function after flap transfer for acute lymphedema. Ann Surg. 1999;229:421–7.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  65. Slavin SA, et al. An investigation of lymphatic function following free-tissue transfer. Plast Reconstr Surg. 1997;99:730–41; discussion 742–3

    CAS  Article  PubMed  Google Scholar 

  66. Adair TH, et al. Quantitation of changes in lymph protein concentration during lymph node transit. Am J Physiol. 1982;243:H351–9.

    CAS  PubMed  Google Scholar 

  67. Adair TH, Guyton AC. Modification of lymph by lymph nodes: II. Effect of increased lymph node venous blood pressure. Am J Physiol. 1983;245:H616–22.

    CAS  PubMed  Google Scholar 

  68. Adair TH, Guyton AC. Modification of lymph by lymph nodes: III. Effect of increased lymph hydrostatic pressure. Am J Physiol. 1985; 249(4): H777–82.

    CAS  PubMed  Google Scholar 

  69. Ito R, et al. Proposed pathway and mechanism of vascularized lymph node flaps. Gynecol Oncol. 2016;141:182–8.

    Article  PubMed  Google Scholar 

  70. Miranda Garces M, et al. A comprehensive review of the natural lymphaticovenous communications and their role in lymphedema surgery. J Surg Oncol. 2016;113:374–80.

    Article  PubMed  Google Scholar 

  71. Edwards JM, Kinmonth JB. Lymphovenous shunts in man. Br Med J. 1969;4:579–81.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  72. Huang JJ, et al. Lymph node transplantation decreases swelling and restores immune responses in a transgenic model of lymphedema. PloS One. 2016;11:e0168259.

    Article  PubMed  PubMed Central  Google Scholar 

  73. Lahteenvuo M, et al. Growth factor therapy and autologous lymph node transfer in lymphedema. Circulation. 2011;123:613–20.

    Article  PubMed  Google Scholar 

  74. Viitanen TP, et al. Lymphatic vessel function and lymphatic growth factor secretion after microvascular lymph node transfer in lymphedema patients. Plast Reconstr Surg Global Open. 2013;1:1–9.

    Article  PubMed  PubMed Central  Google Scholar 

  75. Skobe M, et al. Induction of tumor lymphangiogenesis by VEGF-C promotes breast cancer metastasis. Nature Med. 2001;7:192–8.

    CAS  Article  PubMed  Google Scholar 

  76. Dayan JH, et al. The use of magnetic resonance angiography in vascularized groin lymph node transfer: an anatomic study. J Reconstr Microsurg. 2014;30:41–5.

    Article  PubMed  Google Scholar 

  77. Dayan JH, Dayan E, Smith ML. Reverse lymphatic mapping: a new technique for maximizing safety in vascularized lymph node transfer. Plast Reconstr Surg. 2015;135:277–85.

    CAS  Article  PubMed  Google Scholar 

  78. Chowdhry MRW, Griffiths M. Lymphatic mapping and preoperative imaging in the management of postmastectomy lymphoedema. Gland Surg. 2016;5:187–96.

    PubMed  PubMed Central  Google Scholar 

  79. Mardonado AA, Chen R, Chang DW. The use of supraclavicular free flap with vascularized lymph node transfer for treatment of lymphedema: a prospective study of 100 consecutive cases. J Surg Oncol. 2017;115:68–71.

    Article  PubMed  Google Scholar 

  80. Lee M, et al. Lymphedema of the upper extremity following supraclavicular lymph node harvest. Plast Reconstr Surg. 2015;135:1079e–82e.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  81. Nguyen AT, Suami H. Laparoscopic free omental lymphatic flap for the treatment of lymphedema. Plast Reconstr Surg. 2015;136:114–8.

    CAS  Article  PubMed  Google Scholar 

  82. Cheng MH, et al. A novel approach to the treatment of lower extremity lymphedema by transferring a vascularized submental lymph node flap to the ankle. Gynecol Oncol. 2012;126:93–8.

    Article  PubMed  Google Scholar 

  83. Coriddi M, Skoracki R, Eiferman D. Vascularized jejunal mesenteric lymph node transfer for treatment of extremity lymphedema. Microsurgery. 2017;37:177–8.

    Article  PubMed  Google Scholar 

  84. Smith ML, et al. Heterotopic vascularized lymph node transfer to the medial calf without a skin paddle for restoration of lymphatic function: proof of concept. J Surg Oncol. 2017;115:90–5.

    Article  PubMed  Google Scholar 

  85. Granzow JW, Soderberg JM, Dauphine C. A novel two-stage surgical approach to treat chronic lymphedema. Breast J., 2014;20:420–2.

    Article  PubMed  Google Scholar 

  86. Brorson H. Complete reduction of arm lymphedema following breast cancer: a prospective twenty-one years’ study. Plast Reconstr Surg. 2015;136(4 Suppl):134–5.

    Article  PubMed  Google Scholar 

  87. Campisi CC, et al. Fibro-lipo-lymph-aspiration with a lymph vessel-sparing procedure to treat advanced lymphedema after multiple lymphatic-venous anastomoses: the complete treatment protocol. Ann Plast Surg. 2017. 78(2):184–190.

    CAS  Article  PubMed  Google Scholar 

  88. Brorson H, Svensson H. Liposuction combined with controlled compression therapy reduces arm lymphedema more effectively than controlled compression therapy alone. Plast Reconstr Surg. 1998;102:1058–67; discussion 1068.

    CAS  Article  PubMed  Google Scholar 

  89. Casley-Smith JR. Lymphedema initiated by aircraft flights. Aviat Space Environ Med. 1996;67:52–6.

    CAS  PubMed  Google Scholar 

  90. Graham PH. Compression prophylaxis may increase the potential for flight-associated lymphoedema after breast cancer treatment. Breast. 2002;11:66–71.

    CAS  Article  PubMed  Google Scholar 

  91. Kilbreath SL, et al. Effect of air travel on lymphedema risk in women with history of breast cancer. Breast Cancer Res Treat. 2010;120:649–54.

    Article  PubMed  Google Scholar 

  92. Clark B, Sitzia J, Harlow W. Incidence and risk of arm oedema following treatment for breast cancer: a three-year follow-up study. QJM. 2005;98:343–8.

    CAS  Article  PubMed  Google Scholar 

  93. Dawson WJ, et al. Elective hand surgery in the breast cancer patient with prior ipsilateral axillary dissection. Ann Surg Oncol. 1995;2:132–7.

    CAS  Article  PubMed  Google Scholar 

  94. Gharbaoui I, Netscher DT, Thornby J, et al. Safety of upper extremity surgery after prior treatment for ipsilateral breast cancer: results of an American Society for Surgery of the Hand membership survey and literature review. J Am Society Surg Hand. 2005; 5(4):232-238.

    Article  Google Scholar 

  95. Hershko DD, Stahl S. Safety of elective hand surgery following axillary lymph node dissection for breast cancer. Breast J. 2007;13:287–90.

    Article  PubMed  Google Scholar 

  96. Ahmed RL, et al. Randomized controlled trial of weight-training and lymphedema in breast cancer survivors. J Clin Oncol. 2006;24:2765–72.

    Article  PubMed  Google Scholar 

  97. Sagen A, Karesen R, Risberg MA. Physical activity for the affected limb and arm lymphedema after breast cancer surgery: a prospective, randomized controlled trial with two years follow-up. Acta Oncol. 2009;48:1102–10.

    Article  PubMed  Google Scholar 

  98. Schmitz KH, et al. Weight-lifting for women at risk for breast cancer-related lymphedema: a randomized trial. JAMA. 2010;304:2699–705.

    CAS  Article  PubMed  Google Scholar 

  99. Kilbreath SL, et al. Progressive resistance training and stretching following surgery for breast cancer: study protocol for a randomised controlled trial. BMC Cancer. 2006;6:273.

    Article  PubMed  PubMed Central  Google Scholar 

  100. Johansson K, et al. Low-intensity resistance exercise for breast cancer patients with arm lymphedema with or without compression sleeve. Lymphology. 2005;38:167–80.

    CAS  PubMed  Google Scholar 

  101. McKenzie DC, Kalda AL. Effect of upper extremity exercise on secondary lymphedema in breast cancer patients: a pilot study. J Clin Oncol. 2003;21:463–6.

    Article  PubMed  Google Scholar 

  102. Kim DS, et al. Effect of active resistive exercise on breast cancer-related lymphedema: a randomized controlled trial. Arch Phys Med Rehabil. 2010;91:1844–8.

    Article  PubMed  Google Scholar 

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Acknowledgment

This work was funded via an unrestricted educational grant from ImpediMed.

Conflict of interest

Frank Vicini is a research adviser for ImpediMed. There are no other conflicts of interest.

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Correspondence to Sarah A. McLaughlin MD.

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McLaughlin, S.A., DeSnyder, S.M., Klimberg, S. et al. Considerations for Clinicians in the Diagnosis, Prevention, and Treatment of Breast Cancer-Related Lymphedema, Recommendations from an Expert Panel: Part 2: Preventive and Therapeutic Options. Ann Surg Oncol 24, 2827–2835 (2017). https://doi.org/10.1245/s10434-017-5964-6

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  • DOI: https://doi.org/10.1245/s10434-017-5964-6

Keywords

  • Breast Cancer-related Lymphedema
  • Vascularized Lymph Node Transfer (VLNT)
  • Axillary Reverse Mapping (ARM)
  • ALND Patients
  • Axillary Lymph Node Dissection (ALND)