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From the Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama.
Correspondence: Address correspondence to: Kirby I. Bland, MD, University of Alabama at Birmingham, Department of Surgery, 1808 7th Ave., South, Room 502BB, Birmingham, AL 35233; Fax: 205-975-2199; E-mail: kirby.bland{at}ccc.uab.edu
William Halsted first described secondary lymphedema of the upper extremity in 1921 and termed it "elephantiasis chirurgica."1 The incidence of chronic (more than 6 months) secondary lymphedema of the upper extremity after therapy for breast cancer varies depending upon the definition and method of measurement used. In this era of breast-conservation therapy (lumpectomy with level I and II node dissection), the incidence is reported from 3% to 25% in patients not receiving adjuvant radiotherapy to the axilla. Most clinicians agree that radiotherapy to the axilla after axillary node dissection greatly increases the incidence of lymphedema with the incidence reported to be as high as 50%.
Prevention of lymphodema is undoubtedly the best management strategy. Sentinel lymph node biopsy can provide for adequate nodal staging, whereas lymphedema following this procedure is essentially nonexistent. Although our information is incomplete at present, in the absence of large volume metastatic disease in the sentinel node, it seems that sentinel node biopsy alone is an accurate and objective staging procedure.
Other complications of axillary node dissection include seroma, wound infection, a decreased range of motion of the shoulder, and neuropathy. The incidence of clinically significant seromas is approximately 4%, whereas seromas can be detected by ultrasound in more than 90% of cases.2,3 The incidence of wound infection after axillary dissection ranges from 5% to 14% but can be decreased by the administration of prophylactic antibiotics.4 The incidence of decreased range of motion of the shoulder after axillary node dissection is reported to be as high as 10%. Avoidance of restrictive dressings after surgery and early institution of range-of-motion exercises can reduce the incidence of this complication dramatically. Although 70% to 80% of patients undergoing axillary dissection have loss of sensation in the distribution of the intercostobrachial nerve, brachial plexus neuropathy is observed only in patients receiving adjuvant radiotherapy to the axilla; this incidence is 1.3% when radiation less than 50 Gy is delivered.5
The article by Meric et al. published in this issue of the Annals of Surgical Oncology is a retrospective analysis of the long-term complications associated with breast-conservation therapy.6 The authors confirm that breast-conservation therapy is associated with grade 2 or higher complications in only 9.9% of patients. In comparison to a study reported earlier from the same institution, modern radiotherapy techniques result in fewer radiation-associated complications with the exception of upper extremity lymphedema, which is the dominant complication reported with grade 2 or greater edema expectant in 4.5% of patients. Meric et al. state, "axillary surgery is the most important risk factor for sequelae of breast-conservation therapy" but report that 10 of 13 patients in their series with grade 2 or greater toxicity had both axillary node dissection and axillary radiotherapy. In addition, the authors cite a study confirming the incidence of moderately severe edema to be 5% in patients treated with surgery alone and only 2% in those treated with radiotherapy alone; however, 23% of patients treated with both surgery and radiation experienced this morbidity.7 Undoubtedly, the most important predictor for chronic upper extremity lymphedema following breast-conservation therapy is the combination of axillary lymph node dissection with axillary radiotherapy.
The expanding use of sentinel lymph node biopsy along with an improved understanding of the need for subsequent axillary node dissection will undoubtedly reduce the overall incidence of chronic upper extremity lymphedema. However, the appropriate selection of patients for axillary radiotherapy together with the expert delivery of that therapy are the essential parameters that ensure the lowest possible frequency of chronic upper extremity lymphedema after breast-conservation therapy.
Received for publication May 17, 2002. Accepted for publication May 17, 2002.
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