Assessment of morbidity from complete axillary dissection

Lymphedema of the upper extremity, in addition to being unsightly, can be painful, can limit the arm movements, increases the risk of infection and is psychologically distressing, serving as a constant reminder of cancer. 1. To ascertain the incidence of lymphedema in a hospital based population (in patients undergoing axillary dissection for breast cancer. 2. To determine the clinicoepidemilogical factors associated with the occurrence of lymphedema in these patients. For all patients undergoing axillary dissection, arm measurements were taken in the pre-& post-operative period from at least 3 sites; one in the arm, forearm and wrist (points fixed in reference to fixed bony landmarks). Patients included in this study were followed up for at least 12 months. Circumference difference of more than 5% was taken as mild lymphedema; more than 10% as moderate lymphedema and more than 15% as severe lymphedema. Data was analyzed using SPSS 11.0 statistical software. Of the 231 patients in this study mean age was 51.2 years, majority were housewives (71.9%) and postmenopausal (58.5%). Modified radical mastectomy (MRM), was performed on 203 (87.9%) patients. 57.2% patients had positive lymph nodes. The mean number of positive nodes was 6.52. Majority of the patients received chemo and radio therapy. Overall incidence of lymphedema was 41.1%. The definition of 5-10% increase as mild lymphedema may be a bit severe as in most patients with this increase, lymphedema is not clinically apparent. The incidence of moderate and severe lymphedema in our series is only 7.4%. The incidence of clinically significant lymphedema (moderate to severe lymphedema & symptomatic mild lymphedema) was 16.8%. Only axillary irradiation and pathological nodal status (pN3) emerged as significant risk factors for lymphedema development on multivariate analysis. Lymphedema once established is difficult to treat. Combination of axillary dissection with radiation and more nodal positivity seems to predispose to lymphedema. Prevention by means of sentinel node biopsy in early cases, good surgical technique, arm care post surgery, exercises and massage therapy may help reducing the incidence and/or severity.

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“…The incidence of severe lymphedema is less variable with most studies reporting it in less than 10% of the patients with lymphedema [22,23].…”

Section: Discussionmentioning

confidence: 99%

Study of Incidence of Lymphedema in Indian Patients Undergoing Axillary Dissection for Breast Cancer

Pillai

Sharma

Ahmed

et al. 2010

Indian J Surg Oncol

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“…Despite the evidence in support of intraoperative nerve injury as a causal factor in the development of CPSP, not all patients with CPSP have documented nerve injury or neuropathic pain [6]. Moreover, many patients with objective signs of nerve injury do not develop CPSP [7]. The development of CPSP is a complex process which involves biologic, psychosocial, and environmental mechanisms that have yet to be fully understood [8].…”

Section: Introductionmentioning

confidence: 99%

Preventive Analgesia and Novel Strategies for the Prevention of Chronic Post-Surgical Pain

Clarke

Poon

Weinrib

et al. 2015

Drugs

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Chronic post-surgical pain (CPSP) is a serious complication of major surgery that can impair a patient's quality of life. The development of CPSP is a complex process which involves biologic, psychosocial, and environmental mechanisms that have yet to be fully understood. Currently perioperative pharmacologic interventions aim to suppress and prevent sensitization with the aim of reducing pain and analgesic requirement in acute as well as long-term pain . Despite the detrimental effects of CPSP on patients, the body of literature focused on treatment strategies to reduce CPSP remains limited and continues to be understudied. This article reviews the main pharmacologic candidates for the treatment of CPSP, discusses the future of preventive analgesia, and considers novel strategies to help treat acute postoperative pain and lessen the risk that it becomes chronic. In addition, this article highlights important areas of focus for clinical practice including: multimodal management of CPSP patients, psychological modifiers of the pain experience, and the development of a Transitional Pain Service specifically designed to manage patients at high risk of developing chronic post-surgical pain. Key PointsThe development of chronic post-surgical pain (CPSP) is a complex process which involves biologic, psychosocial, and environmental mechanisms.Ketamine (an NMDA antagonist) appears to be the pharmacologic agent with the most consistent positive preventive analgesic results.The variation in patient response to pharmacologic agents can be explained, in part, by genetic polymorphisms.Understanding the heritability of CPSP will be useful when developing predictive algorithms to determine the preoperative risk for developing CPSP.Psychological treatments delivered before and after surgery have the potential to influence the trajectory of CPSP from the earliest days, in combination with multimodal, preventive analgesia.

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“…Axillary lymph node dissection (ALND) in breast cancer patients still represents the routine surgical method for axillary staging. Although the axillary node status is the most important prognostic factor for recurrence and survival (Fisher et al, 1984;Carter et al, 1989) and information obtained by axillary dissection is useful for planning adjuvant treatment, it is associated with substantial morbidity (Kissin et al, 1986;Ivens et al, 1992;Keramopoulos et al, 1993;Hack et al, 1999;Kakuda et al, 1999) and psychological distress (Maunsell et al, 1993;Tobin et al, 1993;Shimozuma et al, 1999). Hack et al, showed arm/shoulder pain, weakness or numbness in 72% and impaired range of motion in 73% of breast cancer patients after ALND, whereas high levels of quality of life (QOL) were reported.…”

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confidence: 99%

Comparison of quality of life and arm complaints after axillary lymph node dissection vs sentinel lymph node biopsy in breast cancer patients

Peintinger¹,

et al. 2003

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The sentinel lymph node biopsy (SLNB) represents a minimal invasive surgical method for axillary staging in patients with primary breast cancer. In a prospective study, evaluation of quality of life (QOL) and arm morbidity was performed before surgery on a total of 56 breast cancer patients. The EORTC QLQ-C30 and EORTC QLQ-BR23 questionnaires were used for QOL assessment. Assessment of pain was additionally observed using the McGill Pain Questionnaire. Arm mobility was observed by goniometric measurement of arm movement. Data were collected before surgery (t1), 1 week after discharge (t2) and 9 -12 months after surgery (t3). The type of axillary surgery does not seem to affect global QOL at a short-time follow-up, but patients recover sooner after SLNB. Body image and sexual functioning remain stable in both types of axillary surgery. Arm/shoulder pain was reported in 36% of patients after SLNB in comparison to 68% receiving axillary lymph node dissection (ALND), and 'numbness' was reported only in 4% of patients in the SLNB group vs 19.3% after ALND. Abduction, flexion and horizontal adduction of the affected arm show significant impairment after ALND. Breast cancer patients should be counselled about the benefits of SLNB over ALND concerning QOL and postsurgery side effects in a short-term follow-up. Axillary lymph node dissection (ALND) in breast cancer patients still represents the routine surgical method for axillary staging. Although the axillary node status is the most important prognostic factor for recurrence and survival (Fisher et al, 1984;Carter et al, 1989) and information obtained by axillary dissection is useful for planning adjuvant treatment, it is associated with substantial morbidity (Kissin et al, 1986;Ivens et al, 1992;Keramopoulos et al, 1993;Hack et al, 1999;Kakuda et al, 1999) and psychological distress (Maunsell et al, 1993;Tobin et al, 1993;Shimozuma et al, 1999). Hack et al, showed arm/shoulder pain, weakness or numbness in 72% and impaired range of motion in 73% of breast cancer patients after ALND, whereas high levels of quality of life (QOL) were reported. Moderate to severe pain was reported between 20, 23 and 32% (Van Dam et al, 1993;Kuehn et al, 2000;Ververs et al, 2001) and was not significantly related to time since surgery. Other reports suggest that arm problems after ALND are associated with a negative effect on the overall QOL of breast cancer patients (Maunsell et al, 1993;Kuehn et al, 2000). As a result of the need to reduce axillary morbidity, many investigations have been performed on sentinel lymph node biopsy (SLNB), an alternative procedure. Using vital dye and/or radiocolloid, the sentinel node/s as the first lymph node to receive lymphatic drainage from the primary tumour can be identified by a minimal invasive surgical technique. Recently, published data showed no sensory morbidity after SLNB (Giuliano et al, 2000) at a median follow-up of 39 months. Schrenk et al (2000) reported less postoperative arm pain, numbness and arm motion restriction after SLNB at a foll...

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Assessment of morbidity from complete axillary dissection

Cited by 463 publications

References 7 publications

Study of Incidence of Lymphedema in Indian Patients Undergoing Axillary Dissection for Breast Cancer

Study of Incidence of Lymphedema in Indian Patients Undergoing Axillary Dissection for Breast Cancer

Preventive Analgesia and Novel Strategies for the Prevention of Chronic Post-Surgical Pain

Comparison of quality of life and arm complaints after axillary lymph node dissection vs sentinel lymph node biopsy in breast cancer patients

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