Upper limb lymphedema in breast cancer patients in the era of Z0011, sentinel lymph node biopsy and breast conservation

Surgical techniques in breast cancer (BCa) have seen a dramatic change recently with breast-conserving surgery (BCS) and sentinel lymph node biopsy (SLNB). The ACOSOG-Z0011 trial reported equivalence in outcomes for certain patients with SLN metastases treated with axillary lymph node dissection (ALND) or SLNB alone. Our aim was to investigate changes in lymphedema referral patterns in BCa patients over the last 3 years in a specialist unit and to elucidate effects of SLNB, BCS, and Z0011 trial publication on such patterns. A retrospective study was performed over a 3-year period (May 2012-May 2015). Patients were identified using a prospectively maintained lymphedema database and newly referred BCa patients with data availability were included. Overall lymphedema incidence was 11% (19.2% in ALND and 5.1% in SLNB cohort). There was a statistically significant difference in lymphedema referral patterns after Z0011, new referrals reduced by 20% (chi-sq; p = 0.001). Volume of referrals post ALND was reduced by 40% with concomitant 31% rise in those post SLNB alone, reflecting changing surgical patterns. There was a significant change in extent of lymphnode dissection during ALND (p = 0.003). The Z0011 trial in association with wider implementation of SLNB has led to significant changes in the lymphedema referral patterns and extent of ALND.