Page 32 - Read Online

Laustsen-Kiel et al. Plast Aesthet Res 2024;11:17 https://dx.doi.org/10.20517/2347-9264.2024.32 Page 3 of 18

LYMPHEDEMA
Symptoms of arm lymphedema may manifest as swelling, stiffness, pain, heaviness, and restricted
movement [29,30] . When examining chronic pain after breast cancer, BCRL was found to be the highest risk
factor for developing chronic pain [31,32] . A recently published study on breast reconstruction and
upper-extremity function found patients who developed lymphedema to be approximately four times more
likely to report high scores on the disabilities of the arm, shoulder, and hand (DASH) questionnaire,
[33]
signifying upper extremity dysfunction that affect the activity of daily living (ADL) . A systematic review
[34]
of QoL showed that breast reconstruction improves QoL after mastectomy . However, another study
found that BCRL possibly negates the positive effect of breast reconstruction .
[35]
Psychological stress after breast cancer is reported with a range between 22% and 50% in the literature [36,37] .
In a recent German study, 67.3% of patients reported high stress levels, associating BCRL with increased
[38]
distress . In addition, a matched cohort study from 2023 confirmed that patients with BCRL exhibited
lower levels of psychosocial well-being . Consequently, BCRL and upper limb morbidity emerge as the
[39]
primary complications that negatively impact work activity with increased sick leave days and, lastly,
increased socioeconomic burden [40-44] .

DIAGNOSTIC MODALITIES
Lymphedema may manifest several years after breast cancer surgery. A study published in 2017 found that
[45]
13.5% presented with lymphedema at their two-year follow-up , which increased to 41.1% when patients
were examined after ten years . A recent cross-sectional study found the median time from breast cancer
[45]
diagnosis to lymphedema to be four years , suggesting both a potential delay in diagnosis and an evolution
[46]
in limb physiology.
Various diagnostic criteria are present in the literature, encompassing highly advanced technologies, such as
3D live images of lymph flow with SPECT-CT lymphoscintigraphy [47,48] , to simple methods, such as
circumference measurements and patient-reported outcome measures [Table 1] [49-72] . Reliable and valid
assessment tools for BCRL are imperative for diagnosing, monitoring, and comparing treatment
[73]
responses . Lymphoscintigraphy has replaced water displacement as the gold standard, and indocyanine
[74]
green angiography (ICG-A) is likely the next modality . While the presence of dermal backflow in
lymphoscintigraphy is accepted as one of the diagnostic criteria for lymphedema, newer imaging techniques
have yet to establish their clear diagnostic criteria for lymphedema. However, a 10% difference between the
ipsilateral arm, forearm, or both compared to the contralateral side or baseline measurements is often used
as a cut-off value. Notably, the validity of lymphedema diagnosis without baseline measurements is
questionable, as studies have shown a significant variation in volume between the two arms at baseline [75,76] .
In conclusion, a missing baseline measurement can lead to misdiagnosis in around 40% of patients ,
[75]
making baseline measurements imperative in clinical and academic settings to minimize the risk of under or
over-diagnosing lymphedema.

Multiple staging systems for lymphedema exist, with the International Society of Lymphedema (ISL) staging
system being the most widely used [Table 2] [12,76-78] .

ONCOLOGIC BREAST SURGERY - SURGICAL INTERVENTION FOR THE TREATMENT OF
BREAST CANCER
Oncologic breast surgery has evolved significantly since Halsted’s initial introduction of the radical
mastectomy in 1882 . Breast-conserving surgery (BCS) is widely used instead of mastectomy for early
[79]