A total of 421 patients were registered in this study. Among these patients, 38, 1, 2, and 1 having bilateral breast cancers, ipsilateral breast tumor recurrence (IBTR), stage IV disease, and arm injury (torn tendon), respectively, were excluded. Hence, 379 patients were included in the analysis (Fig. 1). Three years postoperatively, there was one case of IBTR, two cases of heterochronous bilateral breast cancer, two cases of additional dissection due to recurrence, and four cases of death, which were excluded from the analyses at 3 and 5 years.
Patients with BCRL who experienced lymphedema at least once in the first 5 years after surgery were compared with those without BCRL. The background characteristics of patients with and without BCRL are shown in Table 1. In the univariate analysis, the risk factors for BCRL included BMI ≥ 25 kg/m2, ALND, hormonal therapy, chemotherapy (docetaxel included), and radiotherapy. The multivariate analysis including these risk factors showed that high BMI, ALND, and radiotherapy remained as the independent risk factors for BCRL (Table 2).
The patient background characteristics according to BMI are shown in Table 3. Patients with high BMI were significantly older (median age, 58 years) compared to those with low BMI (median age, 50 years). The percentages of breast-conserving surgery were 49.7% and 63.4% for low and high BMIs, respectively, indicating that breast-conserving surgery is more common in patients with high BMI than in those with low BMI. There was no difference in axillary procedure, postoperative systemic treatment, or radiation according to BMI.
The incidence rates of new lymphedema at 1, 3, and 5 years postoperatively according to BMI are shown in Fig. 2a. Patients with high BMI showed a significantly higher incidence rate of new lymphedema than those with low BMI at 1 year (p < 0.0001), but not at 3 and 5 years (p = 0.94 and p = 0.47, respectively). In patients with low BMI, the incidence rates of new lymphedema were persistent over time after surgery at approximately 7.0% (p = 0.38), whereas patients with high BMI showed decreased incidence rates of new lymphedema over time after surgery, with 23.5% at 1 year to 9.4% at 5 years. BMI was significantly associated with the incidence of lymphedema at 1 year, even after adjusting for the type of axillary surgery, hormonal therapy, docetaxel administration, and radiotherapy (Table 4).
The incidence rate of new lymphedema was assessed based on the type of axillary surgery (Fig. 2b and 2c). In the ALND group, similar to the whole population, the incidence rate of new lymphedema was significantly higher in patients with high BMI at 1 year postoperatively (p = 0.016), but not at 3 and 5 years (p = 0.21 and p = 0.21, respectively; Fig. 2b), than in those with low BMI. Interestingly, even in patients undergoing SLNB, the incidence rate of lymphedema was high (15.6%) 1 year after surgery, but it was low after 3 years in patients with high BMI. However, the incidence rate was low persistently in patients with low BMI (Fig. 2c). To examine whether the lymphedema persists over time, patients who developed lymphedema 1 year after surgery were followed up at 3 and 5 years according to BMI (Fig. 3). Patients with low BMI who developed lymphedema at 1 year showed a rapid improvement of lymphedema at 3 years, whereas patients with high BMI showed a gradual improvement, indicating a significant difference of the improvement pattern according to BMI (p = 0.04). At 5 years, 26.7% and 50.0% of patients with low and high BMIs, respectively, had retained lymphedema.
We examined the detection rate of BCRL by physical inspection. In the whole population, 43.9% of the BCRL were detected by physical inspection. When sorted by BMI, 49.3% and 31.7% of the BCRL were detected in patients with low and high BMIs, respectively (p = 0.07).