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ORIGINAL ARTICLE
Year : 2019  |  Volume : 7  |  Issue : 4  |  Page : 158-162

A comparison of developing breast cancer-related lymphedema between mastectomy with reconstruction and mastectomy alone among breast cancer patients in Saudi Arabia


1 Medical Intern, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
2 Consultant/Section Head Plastic Surgery and Director, Burn Treatment Center, King Abdulaziz Medical City, Jeddah, Saudi Arabia
3 Department of Medical Education, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia

Date of Submission17-Feb-2019
Date of Acceptance14-Nov-2019
Date of Web Publication12-Dec-2019

Correspondence Address:
Malik M Almailabi
Medical Intern, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ssj.ssj_8_19

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  Abstract 

Context: The study was undertaken to compare developing breast cancer-related lymphedema between those who underwent mastectomy with reconstruction and mastectomy alone.
Aims: One of the most feared consequences after a mastectomy is breast cancer-related lymphedema (BCRL). However, few papers have questioned whether breast reconstruction impacts the development of lymphedema. This study aims to determine if breast reconstruction has an effect on the incidence of BCRL. Furthermore, the effect of the time (immediate vs. delayed) and type (implant based vs. autologous) of breast reconstruction on the development of BCRL will be evaluated.
Settings and Design: We conducted a retrospective cohort study on 320 patients who underwent mastectomy with reconstruction and mastectomy alone between January 1, 2007, and December 31, 2017, at King Abdulaziz Medical City – Jeddah.
Subjects and Methods: We conducted a retrospective cohort study on 320 patients who underwent mastectomy with or without breast reconstruction between January 2007 and December 2017. We reviewed patient medical records progressively to extract patients' characteristics, operative details, and lymphedema information. We divided our sample into two main groups: patients who underwent mastectomy with reconstruction and mastectomy alone. Mastectomy with reconstruction group was subdivided into immediate or delayed reconstruction and autologous or implant-based reconstruction.
Statistical Analysis Used: Statistical analysis was performed using the Statistical Package for the Social Sciences version 20.
Results: Of the total sample size 320, only 78 (24.4% (underwent mastectomy with breast reconstruction (Group 1), while the rest 242 (75.6%) underwent mastectomy alone (Group 2). From both the groups, 24 (7.5%) patients developed lymphedema; there was no significant difference between the breast reconstruction and development of lymphedema (P = 0.67). We subdivided Group 1 (patients who underwent mastectomy with breast reconstruction) into immediate breast reconstruction (40 patients, [51%]) and delayed breast reconstruction (38 patients, [49%]). In comparison between immediate versus delayed breast reconstruction, there was no significant difference between immediate and delayed breast reconstruction (P = 0.67). In terms of the type of reconstruction, we further subdivided Group 1 (patients who underwent mastectomy with breast reconstruction) into implant-based breast reconstruction (42 patients, [54%]), and autologous breast reconstruction (36 patients, [46%]). In comparison between implant-based versus autologous breast reconstruction, there was no significant difference between implant-based and autologous breast reconstruction (P = 0.66).
Conclusions: Although our result is insignificant, it suggests that patients who underwent mastectomy with reconstruction have a lower incidence of BCRL in comparison with those who underwent mastectomy alone. Moreover, our result suggests that immediate breast reconstruction and implant-based breast reconstruction have a lower incidence than delayed and autologous breast reconstruction. Further studies are needed to determine if the breast reconstruction has an effect on the development of lymphedema.

Keywords: Breast cancer, lymphedema, mastectomy, mastectomy with reconstruction


How to cite this article:
Almailabi MM, Daghistani MH, Khan MA. A comparison of developing breast cancer-related lymphedema between mastectomy with reconstruction and mastectomy alone among breast cancer patients in Saudi Arabia. Saudi Surg J 2019;7:158-62

How to cite this URL:
Almailabi MM, Daghistani MH, Khan MA. A comparison of developing breast cancer-related lymphedema between mastectomy with reconstruction and mastectomy alone among breast cancer patients in Saudi Arabia. Saudi Surg J [serial online] 2019 [cited 2020 Sep 27];7:158-62. Available from: http://www.saudisurgj.org/text.asp?2019/7/4/158/272851


  Introduction Top


The most common cancer affecting women worldwide is breast cancer.[1] Due to screening programs, early intervention, and improved treatment, the number of cancer survivors has increased.[1] Despite the advancement in procedural treatments, mastectomies (removal of breast tissue) are still common and are accounting for approximately 20%–30% of treated women with breast cancer.[2] One of the most feared consequences after mastectomy is breast cancer-related lymphedema (BCRL).[3] It is characterized by chronic swelling, localized pain, atrophic skin findings, and recurrent infections. All of these complications have severe psychological and physiological impacts.[3] Moreover, lymphedema has a potential effect on the quality of life due to body image changes, alterations in arm function, and increased complications such as infection and cellulitis.[4]

Clinicians have been recently focused on how to reduce the complications of breast cancer treatment so that breast cancer survivors can have a better quality of life.[5] BCRL- is one such complication that affects approximately 6%–30% of breast cancer survivors.[6] It has been associated with the body mass index (BMI), mastectomy, axillary dissection, axillary irradiation, and lymph node status.[5]

Breast reconstruction after mastectomy is increasingly performed and has become the standard of care in breast cancer management.[7] The goal of breast reconstruction after mastectomy is to restore a breast mound and to maintain health-related quality of life in breast cancer survivors.[8] Few papers have questioned whether breast reconstruction impacts the development of lymphedema.[5],[7],[8],[9],[10] The influence of breast reconstruction on postoperative lymphedema is yet to be clarified. Recent literature has suggested a beneficial reduction in lymphedema after both delayed and immediate breast reconstruction.[11],[12] However, the results of these studies remain highly controversial.[3] According to a recent study published in 2015, reconstruction does not appear to alter lymphedema risk, whereas postoperative radiation therapy, obesity, and extensive axillary dissection greatly increase the risk.[3] Another study was conducted in 2012 suggested that patients who undergo breast reconstruction have a lower incidence and a delay in the onset of BCRL compared with patients who undergo mastectomy alone.[5]

Method of breast reconstruction and the development of lymphedema is another aspect to be discussed. Few studies have focused specifically on whether the reconstruction method affects the development of lymphedema.[13]

In this study, the incidence and time of developing BCRL- in mastectomy with breast reconstruction patients will be compared with those who underwent mastectomy alone. The other risk factors that were mentioned in the literature such as the BMI, axillary dissection, axillary irradiation, and lymph node status will be considered as well. Furthermore, the method of the reconstruction whether it was autologous or implant-based breast reconstruction will be compared in terms of BCRL- development. This study will contribute to the literature and may help the clinicians and the patients to take a decision regarding the breast reconstruction and the method of the reconstruction.


  Subjects and Methods Top


Study design

We conducted a retrospective cohort study on 320 patients who underwent mastectomy with reconstruction and mastectomy alone between January 1, 2007, and December 31, 2017, at King Abdulaziz Medical City – Jeddah. The study was approved by the Institutional Review Board at King Abdullah International Medical Research Centre, Ministry of National Guard Health Affairs. Patients who had lymphedema before the surgery, had lymphedema with 2 weeks of the surgery and resolved spontaneously within 30 days, with missing data, or loss to follow-up were excluded from the study.

Data collection

We used patient files to review medical records progressively from the date of the procedure until the last follow-up. We extracted patients' demographic variables and medical histories from medical records including age, BMI, smoking, comorbidities (diabetes mellitus [DM], hypertension [HTN], and coronary artery disease [CAD]), preoperative chemotherapy or radiotherapy, and postoperative chemotherapy or radiotherapy. Patients' surgical histories were also extracted including mastectomy date and if it was skin-sparing or nipple-sparing, axillary intervention, development of BCRL-, and breast reconstruction. Axillary interventions were classified as without intervention, sentinel lymph node dissection (SLND), and axillary lymph node dissection (ALND). Lymphedema was diagnosed on the basis of clinical diagnosis and arm circumference measurements that documented by the physiotherapy department. Breast reconstruction was classified as immediate or delayed and further classified into autologous or implant based. To compare the development of BCRL between patients who underwent mastectomy with reconstruction and mastectomy alone, we divided our sample into two main groups: patients who underwent mastectomy with reconstruction and mastectomy alone. Mastectomy with reconstruction group was subdivided into immediate or delayed reconstruction and autologous or implant-based reconstruction.

Outcomes

The outcomes of this study were the rates of lymphedema among patients who underwent mastectomy with reconstruction and compare it with the patients who underwent mastectomy alone. We also compared the rates of lymphedema between the different types of reconstruction (immediate vs. delayed and autologous vs. implant based).

Statistical analysis

Statistical analysis was performed using the Statistical Package for the Social Sciences version 20 (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. IBM Corp., Armonk, NY). For expressing the qualitative variable, frequency and percentage were used and for stating the quantitative variable, mean and standard variable were used for normally distributed data, and in case of skewed data, median and interquartile range were used. When comparing the qualitative variables, Chi-square test/Fisher's exact test was used and found the association of the risk factors, with dependent variable regression analysis being done. P < 0.05 was considered statistically significant.


  Results Top


Over the study period, 320 patients were identified. The median age was 48 years, while for the BMI, the median was 28. For the other variables, 24% were diabetic, 28% hypertensive, 4% smoker, 2% had CAD, 45% underwent preoperative chemotherapy, 8% underwent preoperative radiotherapy, 61% underwent postoperative chemotherapy, 46% underwent postoperative radiotherapy, and only 7.5% developed lymphedema [Table 1]. For the axillary intervention, 211 (66%) patients underwent ALND, 37 (12%) patients underwent SLND, and 72 (23%) patients had no axillary intervention. For those who developed lymphedema, the average time from the date of surgery until the date of lymphedema 8.9 months and further details are shown in [Table 2]. The incidence of BCRL was 7.5% in our sample. While applying the Chi-square test to assess the association between lymphedema and the risk factors, it was found that no significant association between lymphedema and age, BMI, DM, HTN, smoking, CAD, or postoperative radiotherapy. However, there was a significant association between lymphedema and preoperative chemotherapy, preoperative radiotherapy, and postoperative chemotherapy. In stepwise logistic regression analysis, “risk factors of preoperative chemotherapy and postoperative chemotherapy were significantly associated with lymphedema.” The results of binary logistic regression model illustrate that those who said “yes” to preoperative chemotherapy are 2.5 times more likely to get lymphedema as compared to those who said “no.” In addition, those who said “yes” to postoperative chemotherapy are 3.3 times more likely to get lymphedema as compared to those who said “no.” Of the total sample size 320, only 24% (78) underwent mastectomy with breast reconstruction (Group 1), while the rest (76%, (242) underwent mastectomy alone (Group 2). From both the groups, 7.5% (24) patients developed lymphedema; there was no significant difference between the breast reconstruction and development of lymphedema (P = 0.67) [Table 3]. We subdivided Group 1 (patients who underwent mastectomy with breast reconstruction) into immediate breast reconstruction (40 patients, [51%]) and delayed breast reconstruction (38 patients, [49%]). In comparison between immediate versus delayed breast reconstruction, there was no significant difference between immediate and delayed breast reconstruction (P = 0.67) [Table 4]. In terms of the type of reconstruction, we further subdivided Group 1 (patients who underwent mastectomy with breast reconstruction) into implant-based breast reconstruction (42 patients, [54%]) and autologous breast reconstruction (36 patients, [46%]). In comparison between implant-based versus autologous breast reconstruction, there was no significant difference between implant-based and autologous breast reconstruction (P = 0.66) [Table 5].
Table 1: Comorbidities and risk factors for developing lymphedema

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Table 2: Time from the date of surgery until the date of lymphedema

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Table 3: Lymphedema versus no lymphedema

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Table 4: Immediate versus delayed breast reconstruction

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Table 5: Implant based versus autologous breast reconstruction

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  Discussion Top


As a result of advances in breast cancer treatment, physicians and patients give more attention for the quality of life after the treatment.[14] One of the most feared complications of breast cancer treatment is lymphedema which results from disruption to the lymphatic system.[14] According to a recent meta-analysis, one in every five patients developed BCRL following breast cancer treatment.[15] Few papers have questioned whether breast reconstruction impacts the development of lymphedema.[5],[7],[8],[9],[10] The influence of breast reconstruction on postoperative lymphedema is yet to be clarified. Recent literature has suggested a beneficial reduction in lymphedema after both delayed and immediate breast reconstruction.[8],[9]

The average time from the date of surgery until the date of lymphedema is 8.9 months. It may be possible that this average time has been impacted by the axillary intervention (66% of the sample had ALND); according to this result from the recent study, early-onset lymphedema (<12 months postoperatively) was associated with ALND.[16] For other factors, our analysis showed a significant association between lymphedema and preoperative chemotherapy, preoperative radiotherapy, and postoperative chemotherapy.

In comparison with a recent study that published in 2017, they found the incidence of lymphedema 9.1%, while in our sample, it was 7.5%.[17] The relatively lower incidence of lymphedema in our sample may be due to differences in patients' characters, treatment course, and rehabilitation program. For the 7.5% who developed BCRL, 79% of them had mastectomy alone, while only 21% had a mastectomy with breast reconstruction, which suggests that breast reconstruction might decrease the possibility of developing BCRL. The result of the study conducted in 2012 supports our findings; it showed that patients who undergo breast reconstruction have a lower incidence and later onset of BCRL compared with patients who undergo mastectomy alone.[5] Another study published in 2015 suggested that reconstruction does not appear to alter lymphedema risk, which indicates that further study should conduct to determine whether breast reconstruction really decreases the incidence of BCRL or not.[3]

Miller et al. in the study suggested that immediate implant reconstruction does not increase the risk of lymphedema compared to mastectomy alone.[7] Our result showed that those who developed lymphedema from breast reconstruction group, 40% of them underwent immediate breast reconstruction, while the higher percent underwent delayed breast reconstruction (60%).

Lee et al. noted that autologous reconstruction was associated with a significantly reduced risk of lymphedema compared with that for tissue expander/implant reconstruction.[13] However, our result suggested against these findings, implant-based breast reconstruction group had a lower incidence of lymphedema when compared with autologous breast reconstruction. Further studies are needed to compare immediate versus delayed breast reconstruction and implant-based versus autologous breast reconstruction since our result conducted on a small population.


  Conclusions Top


Although our result is insignificant, it suggests that patients who underwent mastectomy with reconstruction have a lower incidence of BCRL in comparison with those who underwent mastectomy alone. Moreover, our result suggests that immediate breast reconstruction and implant-based breast reconstruction have a lower incidence than delayed and autologous breast reconstruction. Further studies are needed to determine if the breast reconstruction has an effect on the development of lymphedema.

Acknowledgement

The authors would like to thank Rakan Sultan Alajmi, Abdulgadir Khalid Atyaa, Saeed Mohammed Alamoudi, and Atheel Loai Balkhy, for their roles as data collectors.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Cornelissen AJ, Kool M, Keuter XH, Heuts EM, Piatkowski de Grzymala AA, van der Hulst RR, et al. Quality of life questionnaires in breast cancer-related lymphedema patients: Review of the literature. Lymphat Res Biol 2018;16:134-9.  Back to cited text no. 1
    
2.
Cereijo-Garea C, Pita-Fernández S, Acea-Nebril B, Rey-Villar R, García-Novoa A, Varela-Lamas C, et al. Predictive factors of satisfaction and quality of life after immediate breast reconstruction using the BREAST-Q©. J Clin Nurs 2018;27:1464-74.  Back to cited text no. 2
    
3.
Basta MN, Fischer JP, Kanchwala SK, Fosnot J. Reply: A propensity-matched analysis of the influence of breast reconstruction on subsequent development of lymphedema. Plast Reconstr Surg 2016;137:750e-1e.  Back to cited text no. 3
    
4.
Miller CL, Specht MC, Skolny MN, Horick N, Jammallo LS, O'Toole J, et al. Risk of lymphedema after mastectomy: potential benefit of applying ACOSOG Z0011 protocol to mastectomy patients. Breast Cancer Res Treat 2014;144:71-7.  Back to cited text no. 4
    
5.
Card A, Crosby MA, Liu J, Lindstrom WA, Lucci A, Chang DW. Reduced incidence of breast cancer-related lymphedema following mastectomy and breast reconstruction versus mastectomy alone. Plast Reconstr Surg 2012;130:1169-78.  Back to cited text no. 5
    
6.
Clark B, Sitzia J, Harlow W. Incidence and risk of arm oedema following treatment for breast cancer: A three-year follow-up study. QJM 2005;98:343-8.  Back to cited text no. 6
    
7.
Miller CL, Colwell AS, Horick N, Skolny MN, Jammallo LS, O'Toole JA, et al. Immediate implant reconstruction is associated with a reduced risk of lymphedema compared to mastectomy alone: A prospective cohort study. Ann Surg 2016;263:399-405.  Back to cited text no. 7
    
8.
Zhong T, Hofer S, McCready D, Jacks L. 178: A comparison of postoperative complications between mastectomy and immediate breast reconstruction: Impact on initiation of chemotherapy. Plast Reconstr Surg 2011;127:97.  Back to cited text no. 8
    
9.
Avraham T, Daluvoy SV, Riedel ER, Cordeiro PG, Van Zee KJ, Mehrara BJ. Tissue expander breast reconstruction is not associated with an increased risk of lymphedema. Ann Surg Oncol 2010;17:2926-32.  Back to cited text no. 9
    
10.
Lee KT, Mun GH, Lim SY, Pyon JK, Oh KS, Bang SI. The impact of immediate breast reconstruction on post-mastectomy lymphedema in patients undergoing modified radical mastectomy. Breast 2013;22:53-7.  Back to cited text no. 10
    
11.
Blanchard M, Arrault M, Vignes S. Positive impact of delayed breast reconstruction on breast-cancer treatment-related arm lymphoedema. J Plast Reconstr Aesthet Surg 2012;65:1060-3.  Back to cited text no. 11
    
12.
Klit A, Mejdahl MK, Gärtner R, Elberg JJ, Kroman N, Andersen KG. Breast reconstruction with an expander prosthesis following mastectomy does not cause additional persistent pain: A nationwide cross-sectional study. J Plast Reconstr Aesthet Surg 2013;66:1652-8.  Back to cited text no. 12
    
13.
Lee KT, Bang SI, Pyon JK, Hwang JH, Mun GH. Method of breast reconstruction and the development of lymphoedema. Br J Surg 2017;104:230-7.  Back to cited text no. 13
    
14.
Gillespie TC, Sayegh HE, Brunelle CL, Daniell KM, Taghian AG. Breast cancer-related lymphedema: Risk factors, precautionary measures, and treatments. Gland Surg 2018;7:379-403.  Back to cited text no. 14
    
15.
DiSipio T, Rye S, Newman B, Hayes S. Incidence of unilateral arm lymphoedema after breast cancer: A systematic review and meta-analysis. Lancet Oncol 2013;14:500-15.  Back to cited text no. 15
    
16.
McDuff S, Skolny M, Horick N, Miller C, Warren L, Taghian A. Timing of lymphedema following treatment for breast cancer: When are patients most at risk?. Int J Radiation Oncol Biol Physics 2016;96:S207.  Back to cited text no. 16
    
17.
Nguyen T, Hoskin T, Habermann E, Cheville A, Boughey J. Breast cancer-related lymphedema risk is related to multidisciplinary treatment and not surgery alone: Results from a large cohort study. Ann Surg Oncol 2017;24:2972-2980.  Back to cited text no. 17
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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