Lymphoedème du membre supérieur après cancer du sein - S. Vignes Unité de Lymphologie, Hôpital Cognacq-Jay, Paris - Centre des Maladies du Sein

 
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Lymphoedème du membre supérieur après cancer du sein - S. Vignes Unité de Lymphologie, Hôpital Cognacq-Jay, Paris - Centre des Maladies du Sein
Lymphœdème du membre supérieur
      après cancer du sein

              S. Vignes
    Unité de Lymphologie, Hôpital
         Cognacq-Jay, Paris
Lymphoedème du membre supérieur après cancer du sein - S. Vignes Unité de Lymphologie, Hôpital Cognacq-Jay, Paris - Centre des Maladies du Sein
Lymphœdème (LO)
• Lymphe : système //
veines,…
•Lymphœdèmes
   – 140 millions de
     personnes dans le
     monde (filariose)
   – MS (K sein), MI
     (primitif, K col
     utérin)
• Forme secondaire en
France +++
Lymphoedème du membre supérieur après cancer du sein - S. Vignes Unité de Lymphologie, Hôpital Cognacq-Jay, Paris - Centre des Maladies du Sein
Karpanen T & Alitalo K. Annu Rev Pathol 2008;3:367
Lymphoedème du membre supérieur après cancer du sein - S. Vignes Unité de Lymphologie, Hôpital Cognacq-Jay, Paris - Centre des Maladies du Sein
Physiopathologie du lymphœdème

Szuba A & Rockson S. Vasc Med 1997;2:321
Lymphoedème du membre supérieur après cancer du sein - S. Vignes Unité de Lymphologie, Hôpital Cognacq-Jay, Paris - Centre des Maladies du Sein
associated with a marked mononuclear
Mouse-Tail Model                                                          were    similarly
                                                                                           cell      inflammatory
                                                                                                 fixed    and    decalcified
                                                                                                                                 respons
                                                                                                                                  but were
  Regulation
     RegulationofofAdipogenesis
    We usedincrease
                       Adipogenesis bybyLymphatic
                                in CD45
                                         Lymphatic   Fluid
                                      described cells;
                                                     mouse-ptail  " 0.001).            InOptimum
                                                                                             addition,            theTemperature
                                                                                                                          authors not
                                                #
                our previously                                            bedded in                        Cutting                         me
               nificant
model to examine               increase
                      the effects    of lymphatic Fluid
                                               in the       number
                                                        fluid stasis       of monocytes/macrophages
                                                                          (Tissue-Tek,        Hatfield, Pa.) and sectioned         as atiden
                                                                                                                                           8 to
  Stasis: Part
     Stasis: PartI.I.Adipogenesis,
  n adipogenesis,
               F4/80                 Fibrosis,
                      Adipogenesis, Fibrosis,
                        fibrosis,    and inflammation.
                            immunohistochemistry
Briefly, to disrupt superficial lymphatic vessels, we
                                                                 6 –9
                                                                          !m"for0.001).
                                                                         (p           fresh frozen analysis.
                                                                               Hematoxylin and eosin staining and trichro
               Conclusions:              The       mouse-tail         model        haswerepathologic               findings
                                                                                                                        standardthat       ar
  andand
       Inflammation
          Inflammation
 xcised a 2-mm, full-thickness, circumferential
 egment of to  skinclinical
                       from the   lymphedema,
                                      midportion (20including  mm
                                                                          staining
                                                                          Oil fat
                                                                               red O
                                                                                              performed using
                                                                                     deposition,             fibrosis,onand
                                                                                        staining was performed
                                                                                                                                    techniqu
                                                                                                                                     inflam
                                                                                                                                frozen   secti
 rom the base  Adipogenesis
             Jamie of    the tail)
                   C. Zampell,
      Jamie C. Zampell,        M.D.
                                   M.D.of in
                                           8- toresponse
                                                    10-week-old   to lymphatic
                                                                          to visualize lipid  fluid       stasisBriefly,
                                                                                                   droplets.          closely
                                            Background: Although fat deposition is a defining clinical characteristic of
                                                                                                                              frozenresem
                                                                                                                                       section
 emale C57BL/6 process mice
                          Seth (n   ! 20;
                                Aschen
                               in   obesity.  Jackson
                                         Background:
                                                   This
                                            lymphedema,   Labora-
                                                            Although
                                                             model
                                                            the           slides
                                                                cellular fat
                                                                          thereforewere
                                                                              deposition
                                                                          mechanisms     thatair  adried
                                                                                              isregulate
                                                                                                     defining
                                                                                               provides      and
                                                                                                          this      submerged
                                                                                                                  clinical
                                                                                                                  an
                                                                                                               response            un-in a
                                                                                                                              characteristic
                                                                                                                        excellent
                                                                                                                           remain         me0.
                   Seth    Aschen
ory, Bar Harbor,       Me.). Using
             Evan S. Weitman,            a known.
                                            dissecting
                                   M.D. lymphedema,         micro-
                                                            theofcellular
                                                     The goals            solution
                                                                            mechanisms
                                                                  this two-part         of to
                                                                                study were   oil
                                                                                              that  red    Othe
                                                                                                     regulate
                                                                                                 determine     inthispropylene
                                                                                                                       response
                                                                                                                   effect            glycolu
                                                                                                                                   remain
                                                                                                                          of lymphatic
       Evan S.which
                Weitman,
                      Alan to   study
                               M.D.
                             Yan,  M.D.    the    molecular           mechanisms                that    regulate           the    pathoph
 cope (StereoZoom SZ-4; Leica,              fluidWetzlar,
                                         known.     Theon
                                                  stasis  goalsGer-       lowed
                                                                of this two-part
                                                            adipogenesis            by washes
                                                                                    study
                                                                           and inflammation        toin
                                                                                           were(part      graded
                                                                                                      determine
                                                                                                         I) and howthe propylene
                                                                                                                           effect
                                                                                                                       these           glycol
                                                                                                                                  of lymphat
                                                                                                                               changes
                AlanElhadad,
               Sonia    Yan, M.D. Ph.D. fluid
               ofElhadad,
                   lymphedema.
many), we identified
         SoniaMarina
                             and M.D.
                        De Brot,
                              Ph.D.
                                   ligated deep  (Plast.
                                                 stasis
                                            regulate          Reconstr.lutions,
                                                         on adipogenesis
                                                        the temporal
                                                       collecting       and  Surg.
                                                                             spatial    129:counterstained
                                                                              and inflammation
                                                                                      expression
                                                                                       and        825,(part
                                                                                                     of  fat2012.)
                                                                                                                I) andwithhow these
                                                                                                              differentiation    genes
                                                                                                                                 Harrischang
                                                                                                                                           hem
                                            (part
                                         regulate  II).
                                                      the temporal
ymphatics Babak
              adjacent     to the
                    J. Mehrara,      lateral
                                   M.D.         tail veins    (Fig. and        spatial
                                                                          toxylin         expression
                                                                                      (Dako,                of fat differentiation
                                                                                                   Carpinteria,        Calif.). Analysis  gen
      Marina De Brot, M.D.                  Methods: Adult female mice underwent tail lymphatic ablation and were
                                     (part II).
     Babak J. Mehrara, M.D.
                      New York, N.Y.    euthanized 6 weeks after surgery (n ! 20). Fat deposition, fibrosis, and
                                     Methods:          Adult female mice underwent tail lymphatic ablation and we
                                        inflammation were then analyzed in the regions of the tail exposed to
                  New York, N.Y.     euthanized
                                        lymphatic fluid  6 weeks
                                                              stasis asafter    surgery
                                                                          compared      with (nnormal
                                                                                                  ! 20).       Fat deposition,
                                                                                                          lymphatic     flow.          fibrosis, an
 a chronic disorder that,                       inLymphatic
                                     inflammation
                                        Results:             alsofluid
                                                             were       asstasis
                                                                      then    aanalyzed
                                                                                   persistent in resulted
                                                                                    in the tail            reminder
                                                                                                  the regions                    of
                                                                                                                                  tail cancer
                                                                                                                       of thesubcutane-
                                                                                                              in significant             exposed
                                     lymphatic         fluid stasis
                                        ous fat deposition,         withas acompared
                                                                             2-fold increase withinnormal         lymphatic
                                                                                                       fat thickness      (p " flow.
                                                                                                                                 0.01). In
 es, develops most commonly                                  with        associated
                                                                    stasis  was   associated      psychological
                                     Results: Lymphatic fluid stasis in the tail resulted in significantand
                                        addition,     lymphatic                                 with  subcutaneous        fat    morbidity
                                                                                                                              fibrosis    subcutan
he lymphatic system during              collagen     deposition.
                                     ous fat deposition, with         Development
                                                                     Adipogenesis       in  response
                                                                             a 2-fold increase       ofintargeted
                                                                                                         to    fat thicknesstreatments
                                                                                                             lymphatic
                                        associated with a marked mononuclear cell inflammatory response (5-fold
                                                                                                                           fluid stasis  was
                                                                                                                                   (p " 0.01). I
 reatment.1,2 Remarkably,            addition,
                                             it  is  lymphatic       stasis was      associated      with subcutaneous             fatafibrosis  an
                                        increase
                                     collagen
                                                     in CD45 prevent
                                                    deposition.
                                                                #
                                                                   cells; p "or      treat
                                                                                  0.001).   In lymphedema
                                                                                                addition, the authors has     notedbeen  sig- ham
                                        nificant increase      in theAdipogenesis            in response to lymphatic
                                                                         number of monocytes/macrophages                            fluidbystasis w
                                                                                                                          as identified
ny as 50 percent of patients         associated         with the
                                                              a marked
                                        F4/80 immunohistochemistry      lackmononuclear
                                                                                    of" 0.001).
                                                                                   (p     animal             models. This
                                                                                                    cell inflammatory            response   defic
                                                                                                                                              (5-fo
node dissection          will     go
             Fig. 1. Mouse-tail model
                                        on
                                     increase   to
                                        Conclusions:
                                          of
                                                    in CD45
                                             lymphatic
                                        to clinical
                                                             served
                                                            The
                                                           fluid
                                                                 #
                                                                    cells; as
                                                                  mouse-tail
                                                                 stasis.
                                                       lymphedema,
                                                                             p "   a
                                                                                 modelsignificant
                                                                                     0.001).
                                                                          Representative
                                                                                                 In addition,
                                                                                         has pathologic
                                                                                              photomicrograph  barrier
                                                                                                                     thethat
                                                                                                               findings
                                                                                                                     of a mousefor
                                                                                                                            authors   elucidat
                                                                                                                                        noted a si
                                                                                                                                are similar
                                                                                                                                   tail
                                     nificant      increase     in theincluding
                                                                           numberfat    ofdeposition,      fibrosis, and inflammation.
                                                                                            monocytes/macrophages                  as identified b
a.3 However, 6 weeksdespite        the
                      after lymphatic       fact
                                        Adipogenesis
                                         ligation.   The     molecular (p
                                                            in
                                                           wound
                                     F4/80 immunohistochemistry response
                                                                     is      to
                                                                        marked      bymechanisms
                                                                                  lymphatic
                                                                                       the  bluefluid
                                                                                                  arrow.
                                                                                          " 0.001).     stasis
                                                                                                            Tissues that regulate
                                                                                                                 closely
                                                                                                                      are  resembles
                                                                                                                           harvested     this the
common, proximal
              treatment
                      or distal toremains
                                   the  process
                                       zone         in obesity.
                                               of lymphatic
                                     Conclusions:
                                        which to study the
                                                            The   This model
                                                             lymphedema.
                                                               obstruction
                                                                  mouse-tail        therefore
                                                                               6 weeks
                                                                                              As
                                                                                         afterhas
                                                                                     model       providesP"an
                                                                                                   a   result,
                                                                                                surgery.
                                                                                                    pathologic 20,excellent
                                                                                                                       it
                                                                                                                   20 findings
                                                              # molecular mechanisms that regulate the pathophysiology
                                                                                                                               means with
                                                                                                                           remains
                                                                                                                      mm proximal  that areunkn
                                                                                                                                              simil
             to the zone of lymphatictoofclinical
                                          obstruction;lymphedema,
                                                            D 20, 20 mm    including  Surg.fat
                                                                             distal to the      deposition,
                                                                                               zone
                                                                                                          2012.)fibrosis,
                                                                                                     of lymphatic             and inflammatio
                                                                                                                       obstruction;
 nd is designed#          primarily             to
                                            lymphedema.
             D 30, 30 mm distal toAdipogenesis
                                       the zone of lymphatic lymphatic           to lymphatic fluid stasis closely clinical
                                                                 (Plast. Reconstr.
                                                            in response
                                                                      obstruction.    injury 129:  results
                                                                                                  825,              in     the      resembles fi  th
 ession rather than to achieve       process in obesity.     fat This
                                                                    deposition,
                                                                            model therefore    chronicprovides    inflammation,
                                                                                                                     an excellent meansan        wit
Lymphoedème du membre supérieur après cancer du sein - S. Vignes Unité de Lymphologie, Hôpital Cognacq-Jay, Paris - Centre des Maladies du Sein
Plastic and Reconstructive Surgery • April 2012

Fig. 2. Lymph stasis increases subcutaneous fat deposition. (Above) Representative low-power
mouse-tail cross-sections obtained 20 mm proximal (P!20) or 20 (D"20) or 30 mm distal (D"30) to
the wound (hematoxylin and eosin; original magnification, #2.5). Note the marked deposition of
subcutaneous fat in the distal sections (brackets). (Below) Quantification of fat thickness in the prox-
imal and distal regions of the mouse tail 6 weeks after surgery. Note significant increases in fat
thickness in the distal regions as designated by brackets (***p $ 0.001).
Lymphoedème du membre supérieur après cancer du sein - S. Vignes Unité de Lymphologie, Hôpital Cognacq-Jay, Paris - Centre des Maladies du Sein
Lymphœdème MS après cancer du sein
• Curage axillaire
   – fréquence lymphœdème :19%
   – ganglion sentinelle : 5,6%
• Radiothérapie même si ne
comprenant pas le creux axillaire
• Obésité lors du cancer du sein
(IMC > 30 kg/m2), risque ! 4
• Survenue post-chirurgie voire des
années après… (médiane : 2 ans)
DiSipio T et al. Lancet 2013;14:500
Lymphoedème du membre supérieur après cancer du sein - S. Vignes Unité de Lymphologie, Hôpital Cognacq-Jay, Paris - Centre des Maladies du Sein
204   ESTIMATIONS NATIONALES DE LÌ INCIDENCE ET DE LA MORTALITÖ PAR CANCER EN FRANCE MÖ TROPOLITAINE ENTRE 1990 ET 2018
                      VOLUME 1 : TUMEURS SOLIDES / SEIN

   Lymphœdème après cancer du sein
                  Tendances de lÌ incidence et de la mortalit» en France m» tropolitaine entre 1990 et 2018

• 58500 nx cas de cancer en 2018
               Tendances tous Ç ges

               TABLEAU 4    | Nombre de cas et d» cÀ s en France selon lÌ ann» e Sein
                                                                                                 Ann» e
                                                 1990              1995              2000            2005          2010                2015             2018

                INCIDENCE
                                      Femme     29 970            34 835            41 882       48 468            50 755             55 698          58 459
                MORTALITÖ
                                      Femme     10 172            10 774            10 999       11 290            11 637             12 025          12 146
                MORTALITÖ OBSERVÖ E
                                      Femme     10 141            10 753            10 950       11 308            11 750             12 229

• Fréquence du LO après traitement
               TABLEAU 5
               Sein
                            | Taux dÌ incidence et de mortalit» en France selon lÌ ann» e (taux standardis» s monde)

   – 13-28% après curage axillaire
                                                                           Ann» e                                      Variation Annuelle Moyenne (%)
                                                                                                                       De 1990                    De 2010
                                              1990         1995   2000     2005       2010    2015          2018        á 2018                     á 20 18

   – définitions différentes
                INCIDENCE
                                      Femme   72,8         79,8   90,7     97,0       95,2    98,0          99,9    1,1 [1,0 ; 1,2]            0,6 [0,3 ; 0,9]
                MORTALITÖ
                                      Femme   20,2         20,0   18,8     17,4       16,0    14,7          14,0    1,3 [ 1,4 ; 1,2]           1,6 [ 1,8 ; 1,4]

               ! 2 cm
                MORTALITÖ OBSERVÖ E
                                      Femme   20,1         19,9   18,7     17,4        16,1   14,8

               ! +10%
                FIGURE 2 | Taux dÌ incidence et de mortalit» en France selon lÌ ann» e (taux standardis» s monde TSM)
               Ö chelle logarithmique Sein
Armer J et al. Lymph Res Biol 2005;3:208

DiSipio T et al. Lancet 2013;14:500
                                                                                    Femme
https://www.e-cancer.fr/Expertises-et-publications/Catalogue-des-publications/Rapport-Volume-1-Tumeurs-solides-Estimations-
                                                     100

nationales-de-l-incidence-et-de-la-mortalite-par-cancer-en-France-metropolitaine-entre-1990-et-2018-juillet-2019
                                                     0
                                                g
Lymphoedème du membre supérieur après cancer du sein - S. Vignes Unité de Lymphologie, Hôpital Cognacq-Jay, Paris - Centre des Maladies du Sein
DOI: 10.1097/RLI.0000000000000386                                                     sumptions about x-ray attenuation and impedance properties and

554    www.investigativeradiology.com                                               Investigative Radiology • Volume 52, Number 9, September 2017

                                        Magnetic Resonance Imaging–Based Assessment of Breast
                                          Cancer–Related Lymphoedema Tissue Composition
                                      Marco Borri, MPhys,* Kristiana D. Gordon, MD,†‡ Julie C. Hughes, BSc,* Erica D. Scurr, BSc,*
                                       Dow-Mu Koh, MD, MRCP, FRCR,* Martin O. Leach, PhD, FMedSci, FInstP, FIPEM, FRSB,*
                                                     Peter S. Mortimer, MD, FRCP,†‡ and Maria A. Schmidt, PhD*
                                                                                                                         volumes, fluid accumulated prevalently around the elbow, with substantial involve-
                              Objectives: The aim of this study was to propose a magnetic resonance imaging

          • LO MS : 15-20%
                                                                                                                         ment of the upper arm in only 3 cases. Fat excess volume was generally greater in
                              acquisition and analysis protocol that uses image segmentation to measure and
                                                                                                                         the upper arm; however, the relative increase in epifascial volume, which considers
                              depict fluid, fat, and muscle volumes in breast cancer–related lymphoedema
                                                                                                                         the total swelling relative to the original size of the arm, was in 9 cases maximal
                              (BCRL). This study also aims to compare affected and control (unaffected) arms
                                                                                                                         within the forearm.
                              of patients with diagnosed BCRL, providing an analysis of both the volume and
                                                                                                                         Conclusions: Our measurements indicate that excess of fat within the epifascial

          • Stase lymphatique → modifications
                              the distribution of the different tissue components.
                                                                                                                         layer was the main contributor to the swelling, even when a substantial accumu-
                              Materials and Methods: The entire arm was imaged with a fluid-sensitive STIR
                                                                                                                         lation of fluid was present. The proposed approach could be used to monitor how
                              and a 2-point 3-dimensional T1W gradient-echo–based Dixon sequences, acquired
                                                                                                                         the internal components of BCRL evolve after presentation, to stratify patients for
                              in sagittal orientation and covering the same imaging volume. An automated image
                                                                                                                         treatment, and to objectively assess treatment response. This methodology pro-
                              postprocessing procedure was developed to simultaneously (1) contour the external

            tissulaires, fibrose collagène,
                                                                                                                         vides quantitative metrics not currently available during the standard clinical as-
                              volume of the arm and the muscle fascia, allowing separation of the epifacial and
                                                                                                                         sessment of BCRL and shows potential for implementation in clinical practice.
                              subfascial volumes; and to (2) separate the voxels belonging to the muscle, fat,
                              and fluid components. The total, subfascial, epifascial, muscle (subfascial), fluid        Key Words: breast cancer–related lymphoedema, tissue composition analysis,
                              (epifascial), and fat (epifascial) volumes were measured in 13 patients with uni-          image segmentation, magnetic resonance imaging

            accumulation de Btissu adipeux
                              lateral BCRL. Affected versus unaffected volumes were compared using a
                                                                                                                         (Invest Radiol 2017;00: 00–00)
                              2-tailed paired t test; a value of P < 0.05 was considered to be significant. Pearson
                              correlation was used to investigate the linear relationship between fat and fluid
                                                                                                                             reast cancer–related lymphoedema (BCRL) is a chronic swelling of
                              excess volumes. The distribution of fluid, fat, and epifascial excess volumes
                                                                                                                             the arm, which develops in approximately 20% of women after

            Lymphœdème : 3 composantes,
                              (affected minus unaffected) along the arm was also evaluated using dedicated
                                                                                                                         breast cancer treatment.1 A defining characteristic of BCRL is the accu-
                              tissue composition maps.
                                                                                                                         mulation of both interstitial fluid and fat within the arm, which causes
                              Results: Total arm, epifascial, epifascial fluid, and epifascial fat volumes were
                                                                                                                         both physical and psychological morbidity.2 The buildup of protein-
                              significantly different (P < 0.0005), with greater volume in the affected arms.
                                                                                                                         rich fluid in the interstitium (edema) is caused by impaired lymphatic
                              The increase in epifascial volume (globally, 94% of the excess volume) consti-

            liquidienne (la lymphe), collagène,
                                                                                                                         transport. However, the mechanisms leading to the abnormal deposition
                              tuted the bulk of the lymphoedematous swelling, with fat comprising the main
                                                                                                                         of fat are not fully understood and the links between the lymphatic
                              component. The total fat excess volume summed over all patients was 2.1 times
                                                                                                                         system and adiposity are still under investigation.3 Adipose tissue hy-
                              that of fluid. Furthermore, fat and fluid excess volumes were linearly correlated
                                                                                                                         pertrophy is likely to be promoted by the inflammatory response trig-
                              (Pearson r = 0.75), with the fat excess volume being greater than the fluid in
                                                                                                                         gered by the chronic lymph stasis.4 Furthermore, it has been

            adipeuse
                              11 subjects. Differences in muscle compartment volume between affected and
                                                                                                                         hypothesized that the lymph itself might contain factors that stimulate
                              unaffected arms were not statistically significant, and contributed only 6% to
                                                                                                                         fat cell differentiation and growth.5 The ratio of fat and fluid varies
                              the total excess volume. Considering the distribution of the different tissue excess
                                                                                                                         greatly between lymphoedematous arms, yet first-line treatment for
                                                                                                                         BCRL addresses only the fluid, not the fat. Compression and drainage
                              Received for publication January 26, 2017; and accepted for publication, after revision,   massage attempt to reduce the excess volume by enhancing fluid
                                 April 4, 2017.                                                                          clearance.6 For chronic lymphoedema, liposuction is proposed as a
                              From the *Cancer Research UK Cancer Imaging Centre, The Royal Marsden NHS
                                 Foundation Trust and The Institute of Cancer Research; †Cardiac and Vascular
                                                                                                                         possible intervention.7
                                 Sciences, St George's University of London; and ‡Skin Unit, The Royal Marsden                   Quantification of the volume, spatial distribution, and preva-
                                 NHS Foundation Trust, London, United Kingdom.                                           lence of the different lymphoedematous tissue components could
                              Conflicts of interest and sources of funding: The authors acknowledge the support of       greatly improve patient selection for optimal treatment. However, stan-
                                 the Cancer Research UK and the Engineering and Physical Sciences Research
                                 Council Cancer Imaging Centre in association with the Medical Research Council
                                                                                                                         dard assessment of lymphoedema is currently limited to a measurement
                                 and Department of Health (England) (grants C1060/A10334, C1090/A16464); the             of the size of the affected arm relative to the unaffected arm performed
Lymphoedème du membre supérieur après cancer du sein - S. Vignes Unité de Lymphologie, Hôpital Cognacq-Jay, Paris - Centre des Maladies du Sein
isolates the fat component, the Dixon water image contains the muscle                   Longitudinal Volume Plot
ps of                         and the other tissues, and the STIR image selectively depicts the fluid
  This                                                                                                                       Cumulative tissue volumes are plotted along the length of the
                              (step 2, Fig. 1). The segmentation process is applied to the combined                   arm (Fig. 2). Different colors are assigned to different tissue components:
ualize                        images, and as a result, muscle, fat, and fluid voxels belong to 3 distinct
 asure                        clusters (red, yellow, and blue clusters in Fig. 1). The k-mean algorithm
d and                         is initialized with k = 5 and assigns to the 2 additional clusters:
                              (1) voxels contributing no signal (image noise, gray cluster) and
                              (2) voxels with mixed composition at the tissue interfaces, including
                              connective or fibrotic tissue (white cluster).
                           3. Volume Extraction
                              The program scrolls through each slice and creates 2 separate masks,
                              containing the entire cross-section of the arm (noise excluded) and
 uired                        the muscle, respectively. Erosion/dilation and triangulation algo-
n sep-                        rithms from the IDL library are then used to automatically extract
he pa-                        the external and fascial contours from the masks.17 The muscle and
 g the                        the other subfascial tissue components are contained within the fas-
 g the                        cial contour. Subfacial and total arm volumes are encompassed by
gainst                        the fascial and external contours, respectively, whereas the volume
main-                         between the 2 contours represents the epifascial volume.
e sur-                 Clinical Measurements
ative
  fromRadiology • Volume 52, Number 9, September 2017                           MRI for Lymphoedema Tissue Composition
with a                 Subjects
 . The                        Both the affected and the unaffected arms of 13 patients with di-
                            agnosed unilateral arm lymphoedema after breast cancer treatment were
                            measured with this technique. All patients were adult women who gave
rsion-                      written informed consent as part of a prospective study approved by the
onds,                       National Research Ethics Service. Patient demographics and relevant
sition                      clinical data are reported in Table 1, specifying the arm affected by
                            lymphoedema and the arm predominantly used (dominant).
 ence
                            Volume Measurement
grees,
onds).                           Muscle, fat, and fluid subvolumes can be computed by counting
                          the respective number of voxels (1 voxel = 1 mm3 = 0.001 mL) within
                          the volumes segmented with the image postprocessing procedure. The
lume
ingle         FIGURE 1. following    volumes
                          Step 1: Color         were extracted:
                                         representation            total arm, Dixon
                                                          of the overlapped     subfascial,
                                                                                       waterepifascial,
                          muscle  (subfascial), fluid (epifascial), and  fat
              (red), Dixon fat (green), and STIR (blue) images. The sagittal (epifascial).
 were           (longitudinal) view displays the portion of the arm included in the
econ-                                                                                                                             FIGURE 2. Longitudinal plots of the different tissue volumes within the
                              Volumethe
                analysis—between           Visualization
                                              wrist and the 65% mark (65% of the distance                                         affected and unaffected arms of an example patient (patient 10):
d.              between the elbowThree   and the     shoulder
                                                different         tip). The
                                                            graphical        transversal (cross-sectional)
                                                                         representations       (Figs. 2, 3) are used to           muscle (red), epifascial fat (yellow), epifascial fluid (blue), and total
                view shows visualize
                              how different      tissue components
                                           the distribution                (muscle,
                                                                 of the tissue           fat, and within
                                                                                  components       fluid) arethe arm:             (external, green line).
                separated into different images (red, green, and blue images, respectively)
 3.IDL          on aofrepresentative
    Intensity maps      normalized tissueslice.
                                          excessStep   2: Separated
                                                  volumes   in an exampleDixon    fat,(patient
                                                                            patient     Dixon10).water,   andshows longitudinal intensity maps of the
                                                                                                    A, Image
 onThis         STIR          556
                      transversal       www.investigativeradiology.com
                                    images,     and   segmentation       map     of  a  representative
     of tissue excess along the arm for the 3 tissue components. For fluid and fat, the excess volume         is measured as the difference between© 2017 Wolters Kluwer Health, Inc. All rights reserved.
                                                                                                           slice.
 and unaffected
ydicate         The  k-means
                  volumes,      algorithm
                           whereas           (k =
                                    the epifascial 5) is used
                                                   increase      to segment
                                                             is measured  as thethe  arm
                                                                                 differencevolume.
                                                                                             in volumeStep
                                                                                                        as a 3:
                                                                                                             percentage of the unaffected volume. Darker
   per-greater values and are normalized to the peak values of each measure—for this patient, the peak values are 60 mL (fluid), 90 mL (fat), and
                Fascial and external contours on a representative slice. These encompass,
  d the increase).
 pifascial           B, Image shows the radial intensity map, which gives the distribution of fluid excess in different segments within the epifascial
 summed overrespectively,
ascia)           the longitudinalthe subfacial
                                  extent         andThe
                                         of the arm.    total   arm volumes.
                                                           external               The epifascial
                                                                      segments represent    the layervolume
                                                                                                      below the skin, the internal segments the layer
may assume others are assessing and addressing less press-            Patients with less rigid or shorter cords may have minimal
                ing physical symptoms such as AWS. The purpose of this             cord tension and minimal symptoms until they approach full
                article is to describe the signs and symptoms, diagnosis and       extension and abduction. In our experience, they frequently

       Autres FDR lymphœdème MS
                management, and potential complications of AWS.

                ?@-)%'$).'%170% of cords are palpable, with the implication being that
                the remainder were only visible.13 If the arm is straightened at

• Taxanes en adjuvant
                the elbow and then abducted adequately essentially all cords
                are palpable and many are visible as a linear “tenting” or “fur-
                                                                                   1%2"*3'/'AB@>>$"1'8#C'%1).":>$9
                rowing” of the skin. When the arm is not in the “straightened”     4)&35'EF>&@0>#'*:".%'$"#';@%@C>#'@)'&/#'
Breast surgery                                                                                                                                                                                     \0.0001
                      Original article
                                                                                                                                                       rates of BCRL have been decreasing. Patients und
                                                                       Lumpectomy                                                                                854 (76 %)
                                                                                                                                                        207 (64 %)         647 (81 %)
                                                                                                                                                       sentinel lymph node biopsy (SLNB) have signi
               Risk factors for lymphoedema                    Mastectomy in women with breast cancer: A267                            large
                                                                                                                                         (24 %)         117 (36 %)         150 (19 %)
                                                                                                                                                       lower rates of BCRL than those undergoing axillary
               prospective cohort                       * Axillary surgery                                                                                                                     \0.0001
                                                               NoneThe Breast 28 (2016) 29e36                          Taxanes164     and(14breast
                                                                                                                                             %)
                                                                                                                                                       node dissection (ALND). The rate of BCRL in p
                                                                                                                                                   cancer-related
                                                                                                                                                          0 (0 %) lymphoedema
                                                                                                                                                                           164 (21 %)
                                                                                                                                                       undergoing SLNB has been quoted as being as low
                                                                                                                                                                                                      Chimiothérapie
               S.L. Kilbreath a, *, K.M. Refshauge                      a
                                                               Sentinel, eJ.M.      Beith b
                                                                                     node ,biopsy
                                                                                             L.C. Ward    a, c        d
                                                                                                     (SLNB) , O.A. Ung , E.S. Dylke
                                                                                                                                         a
                                                                                                                                          , %)
                                                                                                                                                       per cent3 – 5 . However, ALND is the surgical proce
                                  e             a
                                                                            lymph
                                                                            ,1                  a, 1
                                                                                                                                     738 (66            165 (51 %)         573 (72 %)
               J.R. French , J. Yee , L. Koelmeyer , K. Gaitatzis                                                    Original article219 (20 %)
al. / The BreastFaculty
                  28 (2016)                                    Axillary     lymph
                                   29e36 Contents lists available at ScienceDirect   node  dissection  (ALND)                                           159 (49 %)          60 (8 %)
                      a
                        of Health Sciences, University of Sydney, Sydney, Australia                                                                    choice for patients with metastasis to axillary lymph
                      b                                             Tumor type
                        Chris O'Brien Lifehouse, Camperdown, Australia                                                                                                                                                                                                 \0.0001
                      c
                      d
                        School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, Australia
                                                                       Invasive Carcinoma                                                     Adjuvant
                                                                                                                                                 Table 3 925  Multivariable
                                                                                                                                                                   (83 %) and Cox
                                                                                                                                                               taxanes              the   proportional
                                                                                                                                                                                      320development
                                                                                                                                                                                           (99 %)               hazards
                                                                                                                                                                                                                  of (76
                                                                                                                                                                                                                 605      %)age-adjusted
                                                                                                                                                                                                                      breast       cancer-related                                            T
                        Royal Brisbane and Women's Hospital, School of Medicine, The University of Queensland, Brisbane, Australia
                      e

                                                                                  The Breast
                        Westmead Breast Cancer Institute, Westmead Hospital, Westmead, Australia
                                                                       Ductal Carcinoma in Situ (DCIS)                                        arm   lymphoedema
                                                                                                                                                 analysis      of (17
                                                                                                                                                              196  risk%)of breast©cancer-related
                                                                                                                                                                                        2015  %) Society Ltdlymphoedema
                                                                                                                                                                                         4 (1 BJS                192 (24 %)
                                                                                                                                                                                     Published by John Wiley & Sons Ltd
                                                                                                                                                                                                                                     by                                                      a
                                                                    Pathologic characteristics                                                   chemotherapy status among women who underwent axillary
                                                                                                                                              M. Cariati1,3 , S. K. Bains1 , M. R. Grootendorst1 , A. Suyoi3 , A. M. Peters5 , P. Mortimer4 , P. Ellis1,3 ,
                                                                                                                                                                                                                                                                                             c
                      a r t i c l e i n f o                                a binvasive  c t size, cm!
                                                                                s t r atumor                                                  M. lymph
                                                                                                                                                 Harries1,3node
                                                                       Median                                                                                ,1.4
                                                                                                                                                               M. Vandissection
                                                                                                                                                                       Hemelrijck2 and1.9
                                                                                                                                                                  (0.05–12.5)           A. D. Purushotham1,3 1.1 (0.05–10.5)
                                                                                                                                                                                           (0.2–12.5)                                        \0.0001                                         w
                      Article history:
                                              j o u r n a l h oMedian
                                                                m eApprospective
                                                                       a g e : lymph
                                                                      number      www       . e ldissected
                                                                                        nodes
                                                                                 study was
                                                                                                  sev
                                                                                           conducted
                                                                                                         i e r . c o mSection
                                                                                                                        /atbincreased
                                                                                                                              rofsResearch
                                                                                                      to identify womenDirectorate
                                                                                                                                   t risk     1
                                                                                                                                           2Oncology,
                                                                                                                                              (0–43)
                                                                                                                                              3for lymphoedema (LE) based
                                                                                                                                                                               2
                                                                                                                                                      and School of Medicine, Cancer
                                                                                                                                                                               6 on  Epidemiology Group, Division1
                                                                                                                                                                                  (1–43)                         of (0–26)                          \0.0001
                                                                                                                                                                                                                    Cancer Studies, King’s College London,
                                                                                                                                                                                                                                       4
                                                                                                                                   of Haematology and Oncology, Guy’s and St Thomas’ NHS Foundation Trust, and Department of Clinical Sciences, St George’s,
                      Received 19 December 2015
                                                        Medianaxillary
                                                                  numbersurgery.   Assessment
                                                                              positive   lymph occurred
                                                                                                  nodesprior to surgery,    within
                                                                                                                       University       4 weeks,
                                                                                                                                   of London,         andand
                                                                                                                                               0 London,
                                                                                                                                                  (0–39)      at5 Department
                                                                                                                                                                  6, 12 andof18     months
                                                                                                                                                                                 Nuclear1Medicine,                  Hazard
                                                                                                                                                                                            (0–39)Brighton and Sussex             ratio
                                                                                                                                                                                                                            0 (0–26)
                                                                                                                                                                                                                       University                             \0.0001
                                                                                                                                                                                                                                   Hospitals NHS Trust, Brighton, UK
                      Received in revised form                following surgery. Following post-surgery assessment,       women were            asked   to Purushotham,
                                                                                                                                                             complete weekly         diaries
                                                                                                                       Correspondence  to: Professor A. D.                  Department   of Research Oncology, King’s College London, 3rd Floor Bermondsey Wing, Guy’s
                      18 April 2016
                      Accepted 24 April 2016
                                                       Radiation   therapy
                                                              regarding    events that occurred in the previous week.       RiskLondon
                                                                                                                       Hospital,    factors SE1were
                                                                                                                                                 9RT, UKgrouped        into demographic,
                                                                                                                                                                                         Model 1
                                                                                                                                                            (e-mail: ea-purushotham@kcl.ac.uk)
                                                                                                                                                                                                                       Model 2                      Model 3   \0.0001
                      Available online 13 May 2016
                                                              lifestyle, breast cancer treatment-related, arm swelling-related, and post-surgical activities. Bio-
                                                        None impedance spectroscopy thresholds were used to determine                          216    (19
                                                                                                                                                   Despite
                                                                                                                                                              %)
                                                                                                                                                               affecting
                                                                                                                                   presence of LE. At 18-months, 241 women
                                                                                                                               Background:
                                                                                                                                                                                      40
                                                                                                                                                                            approximately
                                                                                                                                                                                            (12   %)
                                                                                                                                                                                               one-quarter  of  all
                                                                                                                                                                                                                       176
                                                                                                                                                                                                                     patients
                                                                                                                                                                                                                               (22   %)
                                                                                                                                                                                                                                undergoing    axillary  lymph
                                                              with
                                                        Partial
Breast reconstruction and risk of arm
lymphedema development: A meta-analysis
Charalampos Siotos a, Mohamad E. Sebai b, Eric L. Wan a,
Ricardo J. Bello a, Mehran Habibi b, Damon S. Cooney a,
Michele A. Manahan a, Carisa M. Cooney a, Stella M. Seal c,                                               ARTICLE
Gedge D. Rosson a,* Journal
                       ARTICLE       INReconstructive
                            of Plastic, PRESS & Aesthetic Surgery (2018) ■■, ■
           8                                                                                                   C. Siotos et al.
a
  Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, 601 N. Caroline Street,
Baltimore, MD, USA
b
  Department of Surgery, Johns Hopkins Hospital, 4940 Eastern Avenue, Baltimore, MD, USA
c
  Welch Medical Library, Johns Hopkins University, 1900 E. Monument Street, Baltimore, MD, USA

Received 26 September 2017; accepted 21 January 2018

    KEYWORDS                                     Summary Background: Lymphedema remains a significant complication
    Breast cancer;                               cancer surgery when there is axillary lymph node intervention. Previous systema
    Breast                                       identified risk factors for breast cancer-related lymphedema, including increa
    reconstruction;                          Review
                                                 of lymph nodes dissected and radiotherapy. However, they have not examin
    Lymphedema;
                                                 breast reconstruction on lymphedema occurrence. In this systematic review an

                                             Breast reconstruction and
    Upper-extremity
                                                 wereceiving
           Figure 4 Forest plot analysis of patients soughttotal
                                                              to mastectomy
                                                                  evaluate and
                                                                            thebreast
                                                                                 association     between
                                                                                      reconstruction           breast
                                                                                                     versus total       reconstruction
                                                                                                                  mastectomy only and  (BR) and
    lymphedema;
           lymphedema incidence (exclusion of breast conserving cases).
    Meta-analysis                                Methods: We searched PubMed (1966–2016), Embase (1966–2016), Scopus (
                                                 Google Scholar (2004–2016) for studies involving breast reconstruction and
                                                 lymphedema or breast cancer-related lymphedema. Our primary outcome w
Breast Cancer Res Treat 2015;154:455-61

1955
1962

1998
2006
2009

2010
2005
cohort of patients treated for breast cancer and screened for lymphedema.
,        Patients and Methods
         Between 2005 and 2014, patients undergoing treatment of breast cancer at our institution were
                    Impact of Ipsilateral
         screened prospectively       for lymphedema.   Blood      Draws,
                                                               Bilateral   arm Injections,
                                                                                  volume measurements Blood Pressure were performed
e
 ,                  Measurements,
         preoperatively  and postoperatively   andusing
                                                      Air aTravel      on the
                                                              Perometer.            Risk
                                                                              At each        of Lymphedema
                                                                                          measurement,                     for the
                                                                                                                patients reported
         number ofPatients
                      blood draws,      injections,
                                   Treated       for blood
                                                        Breast pressure
                                                                   Cancer   measurements, trauma to the at-risk arm(s),
         and number of flights taken since their last measurement. Arm volume was quantified using the
                    Chantal M. Ferguson, Meyha N. Swaroop, Nora Horick, Melissa N. Skolny, Cynthia L. Miller, Lauren S. Jammallo,
         relative volume   changeJean
                    Cheryl Brunelle, andA.weight-adjusted       change
                                            O’Toole, Laura Salama, Michelle formulas.     Linear
                                                                             C. Specht, and        random
                                                                                            Alphonse  G. Taghianeffects models were
         used to assess the association between relative arm volume (as a continuous variable) and non-
 f
         treatment risk factors, as well as clinical
chusetts General
                                                        A    characteristics.
                                                             B   S   T    R     A   C    T
edical School, Boston,

             Results Purpose
             In 3,041 measurements,
 l of print at
 ead                                             there
                             The goal of this study  was was     no significant
                                                          to investigate              association
                                                                           the association   betweenbetween       relative
                                                                                                       blood draws,           volume
                                                                                                                      injections, blood change
scember 7, 2015.
             or weight-adjusted
  d No. R01CA139118
                                        changetrauma,
                             pressure readings,    increase    andin undergoing
                                                         cellulitis   the at-risk arm,one    ortravel
                                                                                        and air moreand blood   draws
                                                                                                          increases      (P volume
                                                                                                                    in arm   = .62),ininjections
                                                                                                                                       a
                             cohort of of
             (P = .77), number
  No. P50CA089393
                                       patients
                                          flightstreated
                                                   (one for
                                                         or breast
                                                             two [Pcancer
                                                                        = .77]andand
                                                                                   screened
                                                                                       three for
                                                                                               or lymphedema.
                                                                                                   more [P = .91] v none), or duration of
stional Cancer Institute,
             flights (1 toPatients
 tnnon Research Fund
                                     and[P
                              12 hours    Methods
                                             = .43] and 12 hours or more [P = .54] v none). By multivariate analysis, factors
                             Between 2005 and 2014, patients undergoing treatment of breast cancer at our institution were
             significantly
elated Lymphedema.             associated with increases in arm volume included body mass index $ 25 (P = .0236),
                             screened prospectively for lymphedema. Bilateral arm volume measurements were performed
 efined in theaxillary
                glossary, lymph  node dissection
                             preoperatively            (P , .001),
                                            and postoperatively    usingregional    lymph
                                                                         a Perometer.        node
                                                                                         At each    irradiation patients
                                                                                                  measurement,   (P = .0364),     and
                                                                                                                           reported the cellulitis
  this article and online
             (P , .001).number of blood draws, injections, blood pressure measurements, trauma to the at-risk arm(s),
                         and number of flights taken since their last measurement. Arm volume was quantified using the
           Conclusionrelative volume change and weight-adjusted change formulas. Linear random effects models were
an Antonio Breast
 , San Antonio, TX,
14.
           This study usedsuggests    that
                              to assess   thealthough   cellulitis
                                              association betweenincreases
                                                                     relative armrisk  of lymphedema,
                                                                                   volume  (as a continuous ipsilateral
                                                                                                             variable) andblood
                                                                                                                           non- draws,
           injections, treatment
 y the responsibility of
                         blood pressure      readings,
                                   risk factors, as well and  air travel
                                                         as clinical       may not be associated with arm volume increases.
                                                                     characteristics.
           The resultsResults
es not necessarily          may help to educate clinicians and patients on posttreatment risk, prevention, and
           management3,041
                         In       measurements, there was no significant association between relative volume change
 l views of the National
the National Institutes
                             of lymphedema.
                            or weight-adjusted change increase and undergoing one or more blood draws (P = .62), injections
                            (P = .77), number of flights (one or two [P = .77] and three or more [P = .91] v none), or duration of
            J Clin
s of potential   conflictsOncol 33. © 2015 by American Society of Clinical Oncology
                            flights (1 to 12 hours [P = .43] and 12 hours or more [P = .54] v none). By multivariate analysis, factors
d in the article online at
or contributions are        significantly associated with increases in arm volume included body mass index $ 25 (P = .0236),
  this article.             axillary lymph node dissection (P , .001), regional lymph node irradiation (P = .0364), and cellulitis
                            (P , .001).
                                                                                 the efficacy of such precautionary behaviors    do
 or: Alphonse G.                     INTRODUCTION
 Department of
                         Conclusion
                                                                               not exist, highlighted in a recent statement by the
, Massachusetts                                                                                                             5
Yes v no                            20.35                             1.78 21.05 to 0.36                  20.51 to 4.07          *
                  Abbreviations: ALND, axillary lymph node0.52
                                                                                significantly    20.29
                                                           dissection; BMI, body mass index; RLNR,
                                                                                                     associated
                                                                                                        to 1.34
                                                                                                   regional
                                                                                                                        with increases in               arm vo
                                                                                                                                                    .1126
                                                                                                            lymph node radiation; SLNB, sentinel lymph node biopsy
                 adjusted volume change.
                Association Between                               guide patient
                                                 0.66 Precautionary 20.32
                  *Specified variable or comparison was not analyzed.
                                                                                   education
                                                                                Behaviors
                                                                                     to 1.65
                                                                                                   about
                                                                                                     andlymphedema
                                                                                                            Breast * risk re
                                                20.14             breast cancer20.77 surgery.
                                                                                     to 0.49                          .1781
                Cancer–Related Lymphedema                              in Patients          Undergoing
                                                 0.35                          21.59 to 2.28                           *
                Bilateral14
                               Surgery
                but one of the studies in our comprehensive
                                                 0.13       reviewJ  Clin
                                                                   had    Oncol
                                                                       cohorts     35.
                                                                                 fourfold©
                                                                               20.43 to 0.69  2017
                                                                                            increased by  American
                                                                                                      incidence of    Society
                                                                                                                   lymphedema
                                                                                                                      .8324    o
                                                                                                                              com
                that underwent predominantly ALND, which made them higher-       SLNB.8 Of note, other studies have demonstrated th
                Maria S. Asdourian, Meyha N. Swaroop, Hoda E. Sayegh, Cheryl L. Brunelle, Amir I. Mina, Hui Zheng, Melissa N.
                risk populations because ALND 20.09                              skintopuncture
                                              contributes to an approximately 20.63     0.46     does not represent a risk*factor for l
                Skolny, and Alphonse G. Taghian1.78                                            20.51 to 4.07                                     .1179
                                                                                                          INTRODUCTION
 axillary lymph node dissection; BMI, body mass index; RLNR, regional lymph node radiation; SLNB, sentinel lymph node biopsy; WAC, weight-
nformation
ge.                Risk Factor                            A    B    S     T   R     A     C    T     P        95% CI
d of this
 comparison was not analyzed.
                  BMI ≥ 25                                                              .0404    0.05 to 2.02
er 4, 2017.
                Purpose                                           Although surgical and     targeted     treatments for breast
                This study examined  the lifestyle and clinical risk factors for lymphedema   in a  cohort    of patients who
                  SLNB                                            cancer have improved  .3792 survival,
                                                                                               −1.35 to 0.52 treatment com-
onsibility of   underwent bilateral breast cancer surgery.
udies
essarily in our comprehensive review had cohorts
                  ALND
                                                       fourfold plications  remain a of
                                                                 increased incidence    significant
                                                                                                0.03 to concern
                                                                                            lymphedema
                                                                                        .0464           4.15          for patients.
                                                                                                               compared        with
 dominantly Patients
 he National             and Methods
                 ALND, which    made them higher-            8
                                                       SLNB. Of    note, cancer–related
                                                                Breast   other studies havelymphedema
                                                                                              demonstrated that (BCRL)   ipsilateral
                                                                                                                    Fig 2.      is oneanaly
                                                                                                                           Multivariable
 l Institutes   Between    2013   and  2016, 327 patients who   underwent   bilateral breast  cancer     surgery
                                                                                                     to 2.12 for lary
                                                                                                                     were     pro-
                                                                                                                       lymph node dissecti
  cause ALND contributes       to an approximately
                  Neoadjuvant chemotherapy             skin puncture does not represent     a risk
                                                                                        .0899  −0.15factor        lymphedema;
                spectively screened for arm lymphedema ascomplication   quantified by the   caused     by damagevolume
                                                                                                weight-adjusted        tomass
                                                                                                                           lymph change
                                                                                                                                 index; nodes
                                                                                                                                        RLNR, region
 1521741.       (WAC)     formula.
                   Adjuvant            Arm perometry and subjective
                            chemotherapy                                 data were       collected   preoperatively
                                                                                                  .0161                  radiation; SLNB,
                                                                                                          0.22 to 2.19 and at regular     sentinel lym
                                                                      through        surgical    intervention         and/or      radiation,volu
                                                                                                                         WAC, weight-adjusted
se G.           intervals postoperatively. At the time of each measurement, patients completed a risk assessment
nt of
                   Breast/chest wall radiation
                survey that reported the number of blood draws,       which    may
                                                                       P injections,
                                                                                 95% CI interrupt    the −1.44
                                                                                                  .3879
                                                                                         blood pressure  circulation
                                                                                                               to 3.70   of lymph
                                                                                                           readings, trauma         to thefluid
usetts          at-risk
                   RLNR arm, and number of flights since the           andprevious
                                                                             precipitate        edema
                                                                                         measurement.     of   tothe
                                                                                                                  1.75 arm,
                                                                                                           Generalized
                                                                                                  .9523 −1.86                    breast, or
                                                                                                                           estimating
m St,                                                                .0404    0.05
                                                                              1 -3   to 2.02
 ghian@
                equations were applied to ascertain the association        among
                                                                      trunk.           arm volumesymptoms,
                                                                                     Associated       changes, clinical
                                                                                                                      suchfactors,    and
                                                                                                                            as decreased
                risk exposures.                   −4    −3  −2   −1   0    1       2     3    4
                        DOI: https://doi.org/10.1200/JCO.2017.
                                             Mean Difference in Arm
                                                                      arm
                                                                     .3792
                                                                    Volume
                                                                            functionality,
                                                                             −1.35 to 0.52
                                                                           (WAC)      in Subgroup
                                                                                                 pain,
                                                                                                    (%)
                                                                                                        heaviness, changes in skin
of Clinical     Results
                        73.7494
                The cohort comprised 327 patients and 654.0464
                                                                              quality, and high rates of infection (eg, cellulitis),
                                                                        at-risk arms,       with a median postoperative follow-up
                                                                                  0.03 to 4.15
                that ranged from 6.1 to 68.2 months. Of the 654 arms, 83 developed                      Fig 2. lymphedema,           defined
                                                                                                                Multivariable analysis.  ALND,as axil-
                jco.org                                                                                                       © 2017 by American Society of Clin
otherapy        a WAC $ 10% relative to baseline. On multivariable     .0899 −0.15analysis,
                                                                                        to 2.12      lary lymph
                                                                                                    none    of thenode     dissection;
                                                                                                                       lifestyle    risk BMI,
                                                                                                                                         factorsbody
                                                                                                     mass index; RLNR, regional lymph node
                examined through the risk assessment survey were significantly associated             radiation; SLNB,
                                                                                                                     with   increased WAC.
                                                                                                                        sentinel lymph node biopsy;
 rapy                                                                  .0161      0.22  to 2.19                      2
                Multivariable analysis
                          Downloaded    demonstrated
                                     from                 that having
                                          ascopubs.org by Institut Nationaladebody
                                                                               la Santmass
                                                                                       et de laindex  $ 25
                                                                                                Recherche
                                                                                                     WAC,    kg/mon October
                                                                                                          Mdicale      at the volume
                                                                                                             weight-adjusted    time
                                                                                                                                5, 2017of breast
                                                                                                                                        from  193.054.110.0
                                                                                                                                        change.
                                                 Copyright © 2017 American Society of Clinical Oncology.       All rights reserved.
                cancer diagnosis (P = .0404), having undergone axillary lymph node dissection (P = .0464), and receipt
motherapy (P = .0161). None of the risk exposures                       with a larger sample that includes patients with SLNB

     Risk Factor                                                                                             P     95% CI

     No blood pressures                                                                                          −0.54 to 1.12

     One or more blood pressures                                                                         .0109   −1.26 to 0.03

     No blood draws                                                                                              −0.73 to 0.74

     One or more blood draws                                                                             .4906   −1.20 to 0.58

     No injections                                                                                               −0.68 to 0.74

     One or more injections                                                                              .0928   −2.09 to 0.24

     No trauma                                                                                                   −0.72 to 0.70

     One or more traumas                                                                                 .5705   −3.11 to 1.66

     No flights                                                                                                  −0.72 to 1.13

     One or more flights                                                                                 .2756   −1.09 to 0.40

     No flying hours                                                                                             −0.72 to 1.14

     1−12 flying hours                                                                                   .5223   −1.20 to 0.87

     > 12 flying hours                                                                                   .2524   −1.48 to 0.46

                                             −3          −2           −1           0           1         2          3
                                                  Mean Difference in Arm Volume (WAC) in Subgroup (%)
                                      Fig 1. Univariable analysis. WAC, weight-adjusted volume change.

erican Society of Clinical Oncology                                                                                     JOURNAL OF
eu un lymphœdème (réf. 16).

       LA REVUE PRESCRIRE • AOÛT 2019 • TOME 39 N° 430 • PAGE 611

    Repères
                                                     En pratique Ne pas compliquer inutilement
                                                    la vie quotidienne. Il est utile d’informer les
                                                    femmes qui ont eu un cancer du sein sur le risque
Prévention du lymphœdème                            de lymphœdème et de se limiter aux seuls conseils
                                                    étayés pour les aider à vivre le plus normalement
après cancer du sein                                possible. Proposer une kinésithérapie précoce
S’en tenir aux conseils argumentés                  adaptée après un curage axillaire, faciliter une reprise
                                                    progressive d’activités physiques, donner des
                                                    conseils pour éviter autant que possible un surpoids,
●  Les femmes qui ont eu une chirurgie ou une       limiter le risque de blessure du membre supérieur
radiothérapie pour un cancer du sein reçoivent      du côté du cancer, notamment lors d’activités à
parfois des conseils contraignants au quotidien     risque telles que le jardinage, semblent être des
afin de prévenir la survenue d’un lymphœdème du     mesures suffisantes.
membre supérieur du côté du cancer. Des suivis         En l’absence de lymphœdème, il ne semble pas
de centaines de femmes remettent en question le     préjudiciable d’effectuer des ponctions, injections
bien-fondé de certains de ces conseils.             ou prises de tension sur le membre supérieursupérieur à
                                                    risque. Un antécédent de chirurgie pour cancer du
                                                    sein sans apparition d’un lymphœdème ne justifie
                                                    pas de restreindre les voyages en avion, les expo-
L es femmes qui ont eu un cancer du sein traité
  par chirurgie sont exposées à la survenue d’un
lymphœdème du membre supérieur du côté du
                                                    sitions au soleil, les expositions au froid ou au chaud,
                                                    le port de vêtements compressifs.
cancer, surtout après un curage ganglionnaire ou                                                 ©Prescrire
                                                                                                 ©Prescrire
une radiothérapie. Le lymphœdème est une aug-
mentation de volume du membre liée à l’altération
Mesures "préventives"
• â poids (Shaw C et al. Cancer 2007;110:1868)
• Rééducation épaule, massage
  cicatrice (Torres Lacomba M et al. BMJ 2010)
• Activités physiques : ↓ femmes avec
  LO, ↑ QOL (Johansson K et al. Lymphology
  2002;35:59), intense : haltérophilie
  (Schmitz K et al. JAMA 2010;304:2699)
• Pas de DLM post-opératoire              (Devoogdt
  N et al. BMJ 2011;343:d5326)
Original Article
                                                                   months. The main outcome was BCRL, defined as a relative volume change of
                                                                   RESULTS: A total of 92 patients (7.9%) developed BCRL. Net weight loss vers
 Weight Loss Does Not Decrease Risk of Breast Cancer–Related       protective against developing BCRL (hazard ratio, 1.38; 95% confidence inter
                                                                   loss may be recommended as part of an individualized lifestyle management
                     Arm Lymphedema                                crease the risk of developing BCRL. Cancer 2021;0:1-7. © 2021 American Can

                                    1                 KEYWORDS: breast cancer, breast cancer–related lymphedema, lymphedema
         Sacha A. Roberts, BS        ; Tessa C. Gillespie, BS1; Amy M. Shui, MA2; Cheryl L. Brunelle, PT, MS, CCS, CLT3;
   Kayla M. Daniell, BS1; Joseph J. Locascio, PhD2; George E. Naoum, MD, MMSCI1; and Alphonse G. Taghian, MD, PhD        1

  BACKGROUND: The goal of this study was to determine the relationshipImpact    between of postoperative  weight  changeRisk/Roberts
                                                                                                                          and breast cancer–
                                                             INTRODUCTION                  Weight Change      on BCRL
  related lymphedema (BCRL). METHODS: In this cohort study, 1161 women underwent unilateral breast surgery for breast cancer from
                                                                                                                                         et al

                                                             Advancements in breast cancer (BC) diagnosis and treatment have
  2005 to 2020 and were prospectively screened for BCRL. Arm volume measurements were obtained via an optoelectronic perometer
 TABLE    2. Impact
  preoperatively,       of Weightand
                  postoperatively,  Changes     From
                                      in the follow- up the    1 every 6 to 12 months.
                                                              Preoperative
                                                         setting               Baseline    to follow-
                                                                                        Mean   the Last   Follow-
                                                                                                      up from       Up on BCRL
                                                                                                              preoperative   baseline was 49.1
 Development: Multivariable Analysis (n = 1161)
  months.  The  main outcome  was  BCRL, defined  as a
                                                             years. As a result, there is a growing need to better understand how
                                                       relative volume change  of the ipsilateral arm of ≥10% at least 3 months  after surgery.
                                                             ship. One significant complication of BC treatment is breast cance
  RESULTS: A total of 92 patients (7.9%) developed BCRL. Net weight loss versus net weight gain from baseline to last follow-up was not
                                                                              Univariate
  protective against developing BCRL (hazard ratio, 1.38; 95% confidence interval,                                    Multivariable
                                                                                      0.89-2.13; P = .152). CONCLUSIONS:       2
                                                                                                                             Although   weight
                                                             5 individuals treated for BC will develop BCRL. BCRL results fro
  loss may be recommended as part of an individualized lifestyle management program for overall health, weight loss alone may not de-
                                                                    HR (95%Cancer
                                                                              CI)    Society. P
                                                                                                          3      HR (95% CI)              P
                                                             space, leading to regional swelling. Patients treated for BC are at li
  crease the risk of developing BCRL. Cancer 2021;0:1-7. © 2021 American
 Net weight  loss vs net weight  gain                                       1.45 (0.96-2.18) weight change.  .078                   1.38 (0.89-2.13)            .152
  KEYWORDS: breast cancer, breast cancer–related lymphedema,
 Baseline BMI, kg/m  2                                       able disease        that necessitates.003
                                                                             lymphedema,
                                                                            1.04 (1.01-1.07)
                                                                                                               stressful, time-           consuming, and
                                                                                                                                    1.04 (1.01-1.07)            .005
                                                                                                                                                                        expensiv
 Age at baseline, y
 Race: White vs non-White
                                                             BCRL has          on patient quality.701of life, understanding
                                                                            1.01 (0.99- 1.03)
                                                                            0.87 (0.44-1.74)
                                                                                                             .232                          —
                                                                                                                                           —
                                                                                                                                                         the causes
                                                                                                                                                                 —
                                                                                                                                                                 —
                                                                                                                                                                           of this
 Mastectomy vs lumpectomy                                             Various       studies
                                                                            2.49 (1.64- 3.80) have identified
Effect of manual lymph drainage in addition to
                                    guidelines and exercise therapy on arm lymphoedema
                                    related to breast cancer: randomised controlled trial
 itation science , Marie-Rose Christiaens professor, breast surgeon,
                                       12
                                                 OPEN ACCESS

s research       fellow
      BMJ 2011;343:d5326       1
                                ,  Steven
                         doi: 10.1136/bmj.d5326  Truijen         scientific         coordinator              2
                                                                                                               , Ann Smeets
                     Nele Devoogdt doctor in rehabilitation science , Marie-Rose Christiaens professor, breast surgeon,
                                                                                                        12
                                                                                                                           Page 9 of 12

gynaecological            oncologist            3
                                                 , Patrick
                     and coordinator , Inge Geraerts
                                                                   Neven professor in gynaecological
                                                     research fellow , Steven Truijen scientific coordinator , Ann Smeets RESEARCH
                                                                3                                          1                                                      2

                     breast surgeon , Karin Leunen gynaecological oncologist , Patrick Neven professor in gynaecological
                                                            3                                                             3

en professor oncology in rehabilitation                science 1
                                 , Marijke Van Kampen professor in rehabilitation science
                                                    3                                                                                   1

                                    1
                                        Department of Rehabilitation Sciences, Katholieke Universiteit Leuven and Department of Physiotherapy, University Hospitals Leuven, Leuven,

             Table 4|   Comparison  of cumulative incidence and point prevalence of arm lymphoedema after surgery for breast cancer
                               Belgium; 2Department of Health Care, Artesis University College of Antwerp, Antwerp; 3Multidisciplinary Breast Centre, University Hospitals Leuven
                               and Faculty of Medicine, Katholieke Universiteit Leuven, Leuven
                                                                                                                                                                                             at 3, 6, and 12
             months for different definitions according to treatments to prevent lymphoedema
 olieke Universiteit Leuven and Department of Physiotherapy, University Hospitals Leuven, Leuven,
                                       Intervention (guidelines,3exercise, manual drainage;
 University   CollegeAbstract
                           of Antwerp,
       Definition of lymphoedema
                                                   Antwerp; Multidisciplinary                  group/presumed cumulative incidence of no lymphoedema in intervention
                                                                                                    Breast       Centre,           University          Hospitals          Leuven
                          Objective To determine the preventive effectn=77)
                                                                      of manual lymph drainage         Control cumulative
                                                                                               group)×(presumed (guidelines,      exercise;
                                                                                                                             incidence         n=81) Odds
                                                                                                                                       of no lymphoedema       ratio (95% CI) P value*
                                                                                                                                                           in control
eit Leuven,
       PrimaryLeuven      on the development of lymphoedema related to breast cancer.
                outcome parameter
                                                                                               group/presumed cumulative incidence of lymphoedema in control group)
                                                                                                                or (10/90)×(70/30).
                                    Design Randomised single blinded controlled trial.
             Cumulative incidence, ≥200 mL increase:                                                            Conclusion Manual lymph drainage in addition to guidelines and
                                    Setting University Hospitals Leuven, Leuven, Belgium.
                                                                                                                exercise therapy after axillary lymph node dissection for breast cancer
              At 3 months    Participants 160 consecutive patients with 8  (10%)
                                                                         breast cancer and unilateral                                         6 (7%)                            1.4 (0.5 to   4.4)     0.51
                                                                                                                is unlikely to have a medium to large effect in reducing the incidence of
                             axillary lymph node dissection. The randomisation was stratified for body
              At 6 months                                               11 (14%)                                arm lymphoedema in the short12 (15%)
                                                                                                                                                  term.                         0.9 (0.4 to   2.3)     0.93
                             mass index (BMI) and axillary irradiation and treatment allocation was
              At 12 months†                            group/presumed cumulative incidence of
                                                                        18 (24%)from recruitment
                             concealed. Randomisation was done independently                                                               no lymphoedema
                                                                                                                Trial registration Netherlands Trial Register No NTR 1055.
                                                                                                                                      15 (19%)                                 in intervention
                                                                                                                                                                         1.3 (0.6  to 2.9)     0.45
                             and treatment. Baseline characteristics were comparable between the
                                                                                                          Introduction
             Secondary outcome
 f manual lymph drainage
                               parameters
                                                       group)×(presumed cumulative incidence of no lymphoedema in control
                                                 Seule                  restriction                           :   délai breast cancerd'intervention                                        de    5
                             groups.
         Cumulative incidence,   ≥2 cm increase:
                             Intervention  For six months the intervention   group (n=79) performed a
                                                                                                          Worldwide,                     is the most common cancer in women.
 o breast At 3cancer.
                                                       group/presumed                       cumulative           incidence
                                                                                                          Detection   and  treatment   of
                                                                                                                                        of   lymphoedema
                                                                                                                                            breast                        in
                                                                                                                                                    cancer have significantly  control      group)
                  30-40      treatment  programme    consisting of guidelines about  the  prevention of
               months
                             group (n=81) performed or
                                                                         semaines
                                                                           8 (10%)
                             lymphoedema, exercise therapy, and manual lymph drainage. The control
                                                             (10/90)×(70/30).                               après
                                                                                                          rates.  More1
                                                                                                                         attentionla
                                                                                                          improved over past decades,
                                                                                                                                    is
                                                                                                                                        6 (7%)
                                                                                                                                       now    chirurgie…
                                                                                                                                               therefore paid to
                                                                                                                                                                         1.4 (0.5 to 4.4)
                                                                                                                                              which results in higher survival
                                                                                                                                                                 complications
                                                                                                                                                                                               0.51

  trial. séancesdrainage.       sur
          At 6 months                                  the same   programme    without manual lymph
                                                                          12 (16%)                                                    11 (14%)                           1.2 (0.5 to 2.8)      0.72
                                                                                                          related to treatment, such as arm lymphoedema.
          At 12 months†                                                   20 (27%)                        For a woman with breast16        (20%)lymphoedema is a debilitating
                                                                                                                                        cancer,                          1.4 (0.7 to 3.0)      0.35
         12      semaines                              Conclusion                   Manual
                             Main outcome measures Cumulative incidence of arm lymphoedema
                                                                                                     lymphand   drainage
                                                                                                               incurable   problem  inthat addition
                                                                                                                                            is  caused by    to
                                                                                                                                                          reduced guidelines
                                                                                                                                                                    transport          and
 Belgium.                    and time
         Point prevalence, ≥200        to develop arm lymphoedema, defined as an increase in arm
                                  mL increase:
                                                                                                          capacity of the lymph system (related to the surgery or
          At 3 months                                  exercise            therapy
                             volume of 200 mL or more in the value before surgery.
                                                                            5 (7%)           after      axillary     lymph
                                                                                                          radiotherapy,   or both),node 3 (4%)dissection
                                                                                                                                      sometimes     combined with anfor  1.8 breast
                                                                                                                                                                              (0.4 to 7.8) cancer
                                                                                                                                                                        increase               0.43
  ast cancer     and    unilateral
                             Results Four patients in the intervention group and two in the control
                                                                                                          in lymph   load  (related  to hypertension,    for example).     Twelve
                                                                                                                                                                              23

          At 6 months                                  is Atunlikely
                             group were lost to follow-up.                 4 to
                                                              12 months after (5%)  have
                                                                               surgery,         a medium
                                                                                         the cumulative
                                                                                                          monthsto afterlarge       effect
                                                                                                                         axillary lymph8 (10%)nodein    reducing
                                                                                                                                                    dissection,           the
                                                                                                                                                                the point0.5  (0.1incidence
                                                                                                                                                                                   to 1.7)        of
                                                                                                                                                                                               0.28
 on wasAtstratified
             12 months† for      bodygroup (24%)arm
                             incidence rate for arm lymphoedema was comparable between the
                                                                                                          prevalence   of  arm  lymphoedema        ranges  from  12%   to 26%,
                                                                                                                                                                          4          5

                             intervention
                                                                 lymphoedema
                                                        and control group9(19%)
                                                                             (12%)
                                                                                                  in thethough
                                                                                   (odds ratio 1.3, 95%
                             confidence interval 0.6 to 2.9; P=0.45). The time to develop arm
                                                                                                            short  someterm.           8 (10%)
                                                                                                                          have reported point prevalence rates up to 70%.
                                                                                                                                                                         1.2 (0.4 to 3.3)6
                                                                                                                                                                                               0.71

 reatment      allocationlymphoedema
                                 was was comparable between the two group during the first This wide variety is related to differences in treatment of breast
         Point prevalence, ≥2 cm increase:
Table 3
                            Preventive measure and evidence to support either fact or fiction.
NIH-PA Author Manuscript
                             Preventive measure           Best scientific evidence for             Best scientific evidence against       Fact/Fiction/To be determined
                             Avoid needle sticks of any   Clark [10] – level 2 prospective         Winge 18—Level 3 questionnaire               To be determined
                             type                         observational study (188 patients),      study (311 patients of which 88 had
                                                          findings that 44% patients with          intravenous procedures in affected
                                                          needle stick developed lymphedema        limb). Only 4 patients developed
                                                          as compared with 18% of those            lymphedema in relation to
                                                          without needle sticks                    venipuncture

P                            Avoid Pressure               Louden & Petrek [15, 16] – level 5,
                                                          expert opinion hypothesising that
                                                                                                   Dawson [22] – level 3,
                                                                                                   retrospective cohort (317 patients),
                                                                                                                                                 Probably fiction

r                                                         blood pressure monitoring, tight
                                                          clothing increases blood pressure in
                                                          at risk limb resulting in increased
                                                                                                   no new cases or exacerbations of
                                                                                                   lymphedema in 15 patients with a
                                                                                                   history of lymph node dissection

é
                                                          lymph production.                        who subsequently had elective
                                                                                                   hand surgery with tourniquet
                             Leg/Limb precautions         Ryan [24] – level 5, expert opinion,     None found                                   To be determined

v                                                         crossing legs hinders venous return,
                                                          prolonged standing/sitting results in
                                                          pooling of blood in legs and hence

e                            Avoid Air travel/wear
                                                          increased interstitial fluid leakage.

                                                          Casley-Smith [28] – level 4,             Graham [29] – level 2, Cohort                 Probably fiction

n
                             compressive garments for     questionnaire based retrospective        study (293 patients), no cases of
                             air travel                   study (531 patients), 27 patients        permanent or new onset
NIH-PA Author Manuscript

                                                          reported lymphedema symptoms             lymphedema found after aircraft
                                                          started after aircraft flight & 67       flight taken.

t                                                         patients reported worsening
                                                          lymphedema symptoms after flying.

i                            Maintain a normal body
                             weight
                                                          Shaw [41] – level 1, randomised
                                                          clinical trial (21 patients),
                                                          interventions designed to promote
                                                                                                   Villasor [6] – level 3 non-
                                                                                                   consecutive cohort (51 patients),
                                                                                                   47% patients with lymphedema had
                                                                                                                                                      Fact

o
                                                          weight loss after surgery                normal weight, no correlation
                                                          significantly reduced excess arm         between lymphedema formation
                                                          volume and lymphedema.                   and obesity or weight found.

n                            Avoid extremes of
                             temperature/apply
                             sunscreen/avoid burns
                                                          Hettrick [48] – level 4 prospective
                                                          analysis, 1% of burn population
                                                          found to have lymphedema.
                                                                                                   Chang [45] – level 1 double blind
                                                                                                   randomized study (60 patients),
                                                                                                   heat added to placebo, or
                                                                                                                                                     Fiction

                                                                                                   benzopyrone therapy significantly
                                                                                                   improved symptoms of
                                                                                                   lymphedema compared to placebo
                                                                                                   or benzopyrone alone.

                             Avoid vigorous exercise      Petrek/Foldi [1] level 5 Expert          Schmitz [52] – level 1 randomized                 Fiction
                                                          opinion rationalising that vigorous      trial (141 patients), no increased
                                                          exercise increases blood flow and        incidence of lymphedema in
                                                          consequently lymphatic fluid             exercise group compared to non-
                                                          production.                              exercise control group.
NIH-PA

                           Cemal Y et al. J Am Coll Surg 2011;213:543
Background
Clinical Epidemiology Weight lifting has generally been proscribed for women with breast-cancer related
niversity of Pennsyl-
 icine and Abramson
                                       Weight Lifting in Women with Breast-
                            lymphedema, preventing them from obtaining the well-established health benefits
delphia (K.H.S., A.T., of weight lifting, including increases in bone density.
C.T.W.-S., Q.P.G.); the                    Cancer Related Lymphedema
 atology, University of Methods
School, Minneapolis                Kathryn H. Schmitz, Ph.D., M.P.H., Rehana L. Ahmed, M.D., Ph.D.,
partment of Physical We performed a randomized, controlled trial of twice-weekly progressive weight
ilitation, Mayo Clinic, liftingAndreainvolving Troxel,    Sc.D., Andrea
                                                  141 breast-cancer               Cheville,
                                                                             survivors        M.D.,
                                                                                           with             Background
                                                                                                stableRebecca  Smith,
                                                                                                       lymphedema   ofM.D.,
                                                                                                                        the arm. The
 ). Address reprint re-                   Lorita Lewis-Grant,
                            primary outcome          was the change     M.P.H.,
                                                                              in armM.S.W.,
                                                                                        and hand Cathy  J. Bryan,
                                                                                                    swelling  at 1M.Ed.,
                                                                                                                  year, as measured
               From the Center for Clinical Epidemiology Weight lifting has generally been
 z at the Department
                                           Catherine       T. Williams-Smith,
                                                                with breast-cancerB.S.,        andlymphedema
                                                                                                    Quincy P. Greene
 pidemiology, Univer- through displaced water volume of the affected and unaffected limbs. Secondary
                                weight lifting     in women                                related
               and Biostatistics, University of Pennsyl-
 , 423 Guardian Dr., outcomes included the incidence of exacerbations of lymphedema, number and                   lymphedema, preventing them f
               vania School of Medicine and Abramson
 iladelphia, PA 19104-
                    Table 3.severity   ofOutcomes
                                          lymphedema         symptoms,          and   muscle strength. Participants were required
                                                                                                                  of weight                  lifting, including incre
                             Lymphedema           at 12 Months, According to Study Group.*
mail.med.upenn.edu.                                                           A bs   t r ac t
               Cancer Center,   to wear aPhiladelphia
                                                   well-fitted compression    (K.H.S.,garment      A.T., while            weight lifting.Cumulative Incidence Ratio
 61:664-73.                                                                                                                                   or Mean Difference
               R.S.,      L.L.-G.,
                        Variable
 husetts Medical Society.
                                             C.J.B.,        C.T.W.-S.,           Q.P.G.);
                                                                                    Weight   Lifting the               Control                     (95% CI)             P Value
                                Results
                             Background
               Department       The         of   Dermatology,
                                         proportion           of
 ical Epidemiology Weight lifting has generally been proscribed   women
                                                                             no.University
                                                                                 of patients
                                                                                who       had     an    of
                                                                                                        increase  Methods
                                                                                                            no. of patients
                                                                                                                       ofwomen
                                                                                                                           5%value
                                                                                                                                 or with
                                                                                                                                      morebreast-cancer
                                                                                                                                                in limb swelling             was
                                                                               with  data         value           for
                                                                                                               with data                                                 related
               Minnesota
 ersity of Pennsyl-     Change   in
                             lymphedema,  Medical
                                    interlimb
                                similar        volume        School,them
                                                        difference
                                               in thepreventing
                                                           weight-lifting      Minneapolis
                                                                                     group
                                                                                        from(11%)   obtainingand the  thecontrol        group (12%)
                                                                                                                            well-established             health(cumulative
                                                                                                                                                                       benefits
ne and Abramson
               (R.L.A.);
                           ≥5%
                             of
                                  increase
                                    and
                                incidence
                                   weight
                                                no.
                                              the
                                                    (%)
                                                      Department
                                                    ratio,
                                                lifting,      1.00;    95%
                                                               including
                                                                                   70
                                                                                   of    Physical
                                                                                 confidence
                                                                                 increases
                                                                                                   8 (11)
                                                                                                     ininterval,
                                                                                                         bone
                                                                                                                  We
                                                                                                                   69
                                                                                                                      0.88
                                                                                                                    density.
                                                                                                                            performed
                                                                                                                             to
                                                                                                                                8 (12)
                                                                                                                                  1.13).
                                                                                                                                              1.00 (0.88 to a
                                                                                                                                             As    compared
                                                                                                                                                            1.13)randomized,
                                                                                                                                                                     with
                                                                                                                                                                           1.00
                                                                                                                                                                               the      c
 phia (K.H.S., A.T., ≥5% decrease no. (%)                                          70             13 (19)          69          15 (22)        0.96 (0.81 to 1.14)          0.68
               Medicine
 W.-S., Q.P.G.);    the Mean    control
                                     andvolume
                                   interlimb
                                               group,        the weight-lifting
                                               Rehabilitation,
                                                      discrepancy between Mayo     70
                                                                                              group
                                                                                              Clinic,
                                                                                               −0.69±5.87
                                                                                                          had lifting
                                                                                                                  greater
                                                                                                                   69              involving
                                                                                                                               improvements
                                                                                                                            −0.98±7.31                        141
                                                                                                                                                        in self-reported
                                                                                                                                             −0.29 (−1.94 to 2.51)       breast-cance
                                                                                                                                                                           0.80
  logy, University of Methods   severity of lymphedema symptoms (P = 0.03) and upper- and lower-body strength
                               baseline   and  12  mo (percentage   points)
               Rochester,               MN        (A.C.).        Address65reprint                     re-
hool, Minneapolis               (P
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