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Immediate Breast Reconstruction Is Associated With A Lower Incidence Of Lymphedema Compared to Mastectomy Alone: A Prospective Cohort Study
Cynthia L. Miller, BS, Melissa N. Skolny, MSHA, Lauren S. Jammallo, BS, Jean O'Toole, PT, MPH, Nora Horick, MS, Mina Shenouda, MD, Betro T. Sadek, MD, Michelle C. Specht, MD, Alphonse G. Taghian, MD, PhD, Amy S. Colwell, MD.
Massachusetts General Hospital, Boston, MA, USA.
PURPOSE: Lymphedema is a complication following mastectomy that is characterized by chronic arm swelling, pain, decreased function, and cosmetic deformity. As many as 15-25% of patients will develop lymphedema after treatment for breast cancer. Immediate breast reconstruction is increasingly performed at the time of mastectomy to benefit the patient psychologically and to improve the cosmetic result. However, few studies have examined the association of breast reconstruction with the development of lymphedema. We sought to determine if breast reconstruction following mastectomy influenced the incidence of lymphedema compared to mastectomy alone.
METHODS: From 2005-2012, patients were prospectively screened for lymphedema at a single institute. Arm measurements were performed preoperatively and at 3-7 month intervals postoperatively, with a median post-operative follow-up of 22 months. Lymphedema was defined as ≥10% arm volume increase occurring ≥3 months from surgery, using relative volume change (RVC) for unilateral mastectomy and weight-adjusted volume change (WAC) for bilateral mastectomy cases. Fisher’s exact test and multivariate Cox regression analyses were performed to analyze risk factors for lymphedema.
RESULTS: 559 patients underwent 774 mastectomy procedures. Immediate reconstruction was performed in 74% (574/774) while 26% (200/774) had mastectomy alone. The incidence of lymphedema was significantly lower in patients with immediate reconstruction (5%, 27/574) compared to mastectomy alone (19%, 37/200) (p<0.0001). Of immediate reconstructions, 85% were implant-based and 15% were autologous. The incidence of lymphedema was significantly lower in implant-based reconstruction (4%, 18/486) (p<0.0001) and autologous reconstruction (10%, 9/88) (p=0.044) compared to mastectomy alone. Patients who did not undergo immediate reconstruction were more likely to have a higher Body Mass Index (BMI), and to have undergone axillary lymph node dissection (ALND) and nodal radiation (p<0.0001 for all). After multivariate Cox regression, significant predictors of lymphedema included ALND (HR = 21.8, 95% CI: 8.64 - 54.97, p<0.0001), BMI (HR = 1.06, 95% CI: 1.03 - 1.09, p<0.0001) and immediate reconstruction (HR = 0.57, 95% CI: 0.33 - 0.98, p=0.043), but not nodal radiation (p=0.35) or age (p=0.65). According to type of reconstruction, implant-based (HR = 0.49, 95% CI: 0.26 - 0.90, p = 0.023) but not autologous (HR= 0.84, 95% CI: 0.40 - 1.77, p = 0.65) reconstruction had a significantly lower incidence of lymphedema compared to mastectomy alone.
CONCLUSION: Prospective multivariate analysis confirms that patients who undergo immediate breast reconstruction, in particular those with implant-based reconstruction, have a very low incidence of post-mastectomy lymphedema. The explanation for this finding is not known, however, the association may be related to factors not controlled for in the multivariate analysis. Future research identifying a possible mechanism of reduced lymphedema risk resulting from breast reconstruction may offer novel treatment strategies for patients requiring mastectomy.
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