Analysis Of The Risk Factors Of The Arm Lymphedema Following Axillary Lymph Node Dissection For Breast Cancer

BACKGROUND: Breast cancer is one of the most common malignant tumor of women all around the world. In China, according to the latest assessment of IARC, the new case of female breast cancer amounts to 126,000 each year, which weights 14% of all female malignant tumors each year in China. About 26,600 female die from breast cancer, which weights 8% of all female death because malignant tumor. The incidence of breast cancer in China increases about 3% per year. The survival rate of breast tumor tops all the female malignant tumors, and the five-year survival rate can be 85.16%. However, arm lymphedema following axillary lymph node dissection(ALND) for breast cancer is a common complication, and happens to 10-35% of the postoperative patients. As to the risk factors of lymphedema following ALND, different researches have different results.Method: 60 unilateral breast cancer patients who received axillary lymph node dissection(ALND) were surveyed mainly about eight factors that may induce arm lymphedema following ALND: age, clinical stage of tumor, radiotherapy, other complication(late healed/infection/effusion of the wound), postoperative functional exercise, dominant hand, physical exercise and hypertension, and the statistics were analyzed with logistic regression(SPSS v13.0).Results: Four factors are related to arm lymphedema following axillary lymph node dissection for breast cancer: 1. radiotherapy (OR=8.966) 2. other postoperative complication(OR=8.493) 3.hypertension (OR=5.609)4.postoperative functional exercise(OR=0.194) .Conclusion: Among these four factors, radiotherapy ,other postoperative complications and hypertension are risk factors, and postoperative functional exercise is a protective factor. 1,Radiotherapy(RT) is the most important risk factor of arm lymphedema following ALND. RT related stenosis in lymph capillaries and fibrosis in local subcutaneous tissue may significantly decrease the local lymph backflow, thus induce arm lymphedema. A report showed that the incidence rate of arm lymphedema following ALND can be 35%, so postoperative RT should be given only under strict indication. However, no standard has been made yet, the common indications for the use of postmastectomy radiotherapy (PMRT) is as follow, 1. BCS with negative lymph node, breast RT is necessary; BCS with four or more positive lymph nodes, breast plus supraclavicular RT is necessary; 2. modified radical mastectomy, high-risk group includes women with four or more positive lymph nodes or the tumor is bigger than 5cm(T3) in diameter, or the tumor invade the skin/chest wall, or the tumor can not be excised thoroughly, chest wall plus supraclavicular RT is necessary. Currently, the role of PMRT for patients with one to three positive lymph nodes remains uncertain and should be tested in a randomized controlled trial. Also, skin care should be strengthened after RT, lest local skin impairment or infection. As to the therapy to arm lymphedema, conservative or surgical therapy can be given according to the severity of lymphedema. 2,Other postoperative complication like late healed or infection, or effusion of the wound, often infer a poor local/ systemic resistance, or malpractice. When they occur, resistance will get worse and may end up with arm lymphedema. 3,Hypertension and some hypotensors may also induce arm lymphedema: Hypertesion leads to water-sodium retention, which leads to an increase of extracellular fluid volume , and arm lymphedema happens when local lymph backflow decrease as a result of ALND. Venous pressure rises when cardiac functional insufficiency happens, and lymph backflow is obstructed, thus induce arm lymphedema. Calcium channel blocker(CCB)-induced oedema is caused by increased capillary hydrostatic pressure that results from preferential dilation of pre-capillary vessels. Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) cause post-capillary dilation and normalize hydrostatic pressure, so ARB/CCB and ACEI/CCB combination therapy is more effective than CCB monotherapy in controlling blood pressure as well as preventing arm lymphedema.