Lymphedema (arm swelling) is a significant complication that may develop following local and regional treatment of breast cancer. Lymphedema is a serious physical and psychological morbidity that can result in cosmetic deformity, functional loss in the arm, and recurrent episodes of cellulitis and/or lymphangitis. Factors such as axillary surgery, radiotherapy, obesity, venous obstruction, delayed wound healing, and infection are reported to contribute to the development of lymphedema (1,2,3). In this study, we aimed to evaluate the incidence of lymphedema in patients undergoing modified radical mastectomy (MRM) for invasive breast cancer and assess tumor characteristics and treatment-related factors that may influence its development.
Methods and Materials
Data from patients who underwent MRM for breast cancer at the 2nd General Surgery Clinic of Şişli Etfal Training and Research Hospital between 1999 and 2003 were retrospectively evaluated. Axillary dissection included removal of level I and II lymph nodes, while preserving the pectoralis minor muscle. The axillary vein was identified but not fully stripped, and level III lymph nodes were not removed. Dissection superior to the axillary vein was avoided. Sharp dissection techniques were used, axillary vein branches were ligated, and careful hemostasis was performed. Aspirative closed drains were used.
Patient age, tumor T stage, axillary nodal involvement (N stage), TNM stage, postoperative radiotherapy (RT) status, development of arm lymphedema, and time of onset were recorded. Lymphedema was defined as a circumferential difference of at least 2 cm between the arm on the surgical side and the unaffected side, measured 10 cm above or below the lateral condyle. Statistical analysis was performed using Pearson’s Chi-square and Fisher’s Exact tests, with p<0.05 considered significant.
Results
MRM was performed on 93 female patients, with a mean age of 49.9 ± 13.7 years (range 17-83) and a mean follow-up of 40.8 ± 14.8 months (12-72 months) (Table 1). Tumor T stages were distributed as follows: T1 (11 patients, 1.8%), T2 (49 patients, 52.7%), T3 (27 patients, 29%), T4 (6 patients, 6.5%) (Table 2). Axillary nodal involvement (N stage) was distributed as follows: N0 (35 patients, 37.6%), N1 (26 patients, 28%), N2 (32 patients, 34.4%) (Table 3). TNM staging showed Stage I (7 patients, 7.5%), IIA (26 patients, 28%), IIB (21 patients, 22.6%), IIIA (33 patients, 35.5%), and IIIB (6 patients, 6.5%) (Table 4).
Forty-four patients (47.3%) received RT. Lymphedema developed in 7 patients (7.5%) (Table 5). The earliest cases of lymphedema were observed at postoperative month 6 in two patients, while the latest onset occurred at month 44. The mean time to lymphedema development was 24.8 ± 16.5 months. No significant difference was found between the mean ages of patients with and without lymphedema (p>0.05).
Lymphedema rates by T stage were as follows: T1 (0%), T2 (4.1%), T3 (14.8%), T4 (16.7%). Although rates increased with T stage, the differences were not statistically significant (p>0.05). By nodal involvement, lymphedema rates were: N0 (2.9%), N1 (11.5%), N2 (9.4%). Again, differences were not statistically significant (p>0.05). By TNM stage, rates were: Stage I (0%), IIA (3.8%), IIB (0%), IIIA (15.2%), IIIB (16.7%). Rates increased with TNM stage but were not statistically significant (p>0.05).
RT significantly increased the risk of lymphedema. Among 44 RT recipients, 6 (12.6%) developed lymphedema, compared to 1 (2%) of 49 non-RT patients (p<0.05).
Discussion
Breast cancer is the most common cancer type among women (2). Advances in early diagnosis and multidisciplinary treatment have significantly improved survival rates. However, “quality of life” has become an increasingly important issue for long-term survivors (4,5). Lymphedema is a chronic major complication that negatively impacts quality of life.
Reported lymphedema incidence rates following breast cancer treatment range from 4% to 30% (1,4,6-12). Risk persists throughout the patient’s lifetime, with cumulative incidence increasing over time. Meriç et al. (8) reported a mean onset of 17 months, ranging from 1 to 109 months post-treatment. In our study, the mean onset was 25 months, with the earliest and latest cases observed at 6 and 44 months, respectively.
Lymphedema etiology remains unclear, but numerous risk factors have been identified, including body mass index (7,10,14-16), age (16,17), surgical incision type (18), arm infection history (13,18), tumor stage and size (9,10,12,14), tumor grade (10), number of lymph nodes removed (9,12), axillary dissection extent (6,8,10), and RT (6,7,9,14,19). Geller et al. (17) reported increased lymphedema risk in women under 50, but many studies, including ours, found no significant age-related differences (7,10,14,17).
Postoperative RT was the only factor significantly associated with lymphedema in our study. Lymphedema occurred in 12.6% of RT recipients compared to 2% of non-RT patients. RT combined with axillary dissection is known to have a synergistic effect, further increasing lymphedema risk (1,3,6,7,9,14,19).
Conclusion
RT is a significant risk factor for lymphedema development following MRM. As the follow-up period increases, so does the cumulative incidence of lymphedema. Continuous and regular monitoring of patients for arm swelling is crucial for early diagnosis and conservative management.
