Abstract P1-20-22: Evaluating the use of targeted axillary dissection and comprehensive physical therapy to reduce the risk of lymphedema in node-positive breast cancer patients
Authors: Amin Miral , Shah Karan 
Published: March 2020

Background: Before the advent of neoadjuvant chemotherapy (NC), the standard of care for node-positive breast cancer patients was to undergo complete axillary lymph node dissection (ALND). These patients also generally receive adjuvant radiation (AR), including axillary lymph node radiation. However, ALND and AR have been shown to increase the risk of secondary lymphedema to 20-30%. When treated with NC, resolution of all nodal metastasis to pathologically confirmed node-negative disease occurs in approximately 40% of patients. Such patients are eligible for targeted axillary dissection (TAD), which involves removal of clipped biopsy-positive node and sentinel nodes. TAD patients also receive AR, and their lymphedema rate has been reported at 10-12%. There is considerable variability on recommended protocols for lymphedema prevention in these patients. The goal of this study was to investigate whether TAD in combination with comprehensive physical therapy can further reduce the risk of lymphedema in node-positive breast cancer patients receiving NC.

Methods: An IRB-approved retrospective review was conducted of 29 consecutive patients undergoing NC and localization of axillary nodes for their breast cancer surgery between Aug 2016 and Dec 2018. Patients with negative nodes intra-operatively underwent TAD only whereas those with positive nodes underwent ALND. Comprehensive physical therapy program included deep myofascial release, range of motion exercises, and stretching. Patients with ALND were provided prophylactic compression sleeve for 3 months. The main outcome measures were Lymphedema Index (L-DEX) scores (normal range -10 to +10) and range of motion at 1 month post-surgery. Lymphedema was also monitored clinically for a median duration of 7 months post-surgery. Baseline characteristics and outcomes between the TAD and ALND groups were compared.

Results: A total of 16 patients underwent TAD whereas 13 underwent ALND (Table 1). Post-NC stages were 11 Stage 0, 3 Stage I, 9 Stage IIB, 5 Stage III A, 1 Stage IIIC. 10 patients completed breast conservation surgery, 13 had mastectomy with implant-based reconstruction (9 nipple-sparing mastectomy, 4 skin-sparing mastectomy), and 6 had mastectomy without immediate reconstruction. The clipped node was localized at a median of 1 day (range 1-35) before surgery, and 100% of the clipped nodes were retrieved. 28/29 (97%) patients underwent AR (1 patient refused). There were no statistically significant differences in pre-op L-DEX and 1-month post-op L-DEX between TAD and ALND groups. At 1-month post-op, 22 patients had full and 7 had limited range of motion. Two ALND patients with BMI of 25.8 and 32.2 kg/m2 developed lymphedema at 9.2 and 16 months respectively after surgery and were successfully managed with physical therapy. None of the 29 patients experienced tumor recurrence after a median follow-up of 7 months.

Conclusion: This preliminary study found no evidence of lymphedema in TAD and ALND patients at one month following surgery. After a median follow-up of 7 months, 15% of ALND patients but no TAD patients experienced lymphedema. Prospective studies with large sample sizes are needed to further investigate the role of TAD combined with physical therapy in reducing the risk of lymphedema.

Table 1: Comparison of patient characteristics and outcomes between TAD and ALND (N=29)CharacteristicTAD (n=16)ALND (n=13)P-valueMedian age in years49.654.50.28Median BMI in kg/m226.432.20.16Response to NCComplete response10 (62.5)1 (7.7)0.01*Partial response6 (37.5)9 (69.2)No response0 (0)3 (23.1)Median sentinel nodes removed320.02*Median size of clipped node (mm)15200.04*Median follow-up duration in months7.75.80.37Median number of PT visits380.20Median L-DEX score pre-op-1.5-1.30.73Median L-DEX score 1 month post-op-2.72.10.55Median L-DEX score difference (post-op minus pre-op)0.4-0.10.98Range of motion 1 month post-opFull14 (87.5)8 (61.5)0.10Limited2 (12.5)5 (38.5)Deep myofascial release to axilla and breast 1 month post-opYes12 (75)11 (84.6)0.53No4 (25)2 (15.4)Lymphedema during long-term follow-upYes0 (0)2 (15.4)No16 (100)11 (84.6)0.10Values in parentheses are column percentages*P &lt;= 0.05

Citation Format: Miral Amin, Karan Shah. Evaluating the use of targeted axillary dissection and comprehensive physical therapy to reduce the risk of lymphedema in node-positive breast cancer patients [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P1-20-22.