2017年10月，美国乳腺外科医师学会和外科肿瘤学会《外科肿瘤学年鉴》正式发表梅奥医院佛罗里达分院、波士顿阿卡里医院、洛杉矶加利福尼亚大学、英国伦敦帝国学院、明尼苏达州雅林娜医院、迈阿密癌症研究所、英格兰和爱尔兰乳腺外科学会、英格兰皇家外科学院、斯坦福大学、德克萨斯大学MD安德森癌症中心、温斯罗普保罗洛克菲勒癌症研究所、纽约淋巴水肿联盟、意大利热那亚大学圣马丁医院、纽约霍夫斯特拉大学、蒙特菲奥里医学中心、阿尔伯特爱因斯坦医学院、北岸长岛医院、福尔克心血管研究中心、蒙特菲奥里爱因斯坦癌症中心的美国乳腺外科医师学会多学科专家组推荐意见：乳腺癌相关淋巴水肿诊断、预防和治疗的临床医师注意事项。
第一部分：定义、评定、教育和未来方向
推荐意见一：专家组一致认为，临床医师应该制定监测计划，因为早期诊断带来早期治疗，并且增加控制疾病负担的可能性。
推荐意见二：专家组一致认为，所有乳腺癌患者两侧手臂的初始测量和随访测量至关重要。所有测量技术均存在优点和缺点，制定综合测量策略时应该进行权衡，包括结合客观和主观的测量方法。
推荐意见三：专家组一致认为，临床医师应该采取个体化医学策略以尽量减少腋窝手术，应该对常规使用乳房切除术或区域淋巴结放疗进行质疑，并且应该使用基因组检测指导使用化疗以最大限度地减少多种疗法的叠加效应。患者应该保持健康的体重、体重指数。
推荐意见四：专家组一致认为，外科医师应承认并且接受淋巴水肿风险存在，同时在术前和随访复诊时对自己及其患者进行这些风险教育。教育应该在治疗后生存期持续开展，并且纳入生存医疗计划。
推荐意见五：对于淋巴水肿的病理生理学机制认知可能过于简单化。淋巴阻塞、炎症、免疫反应、补体活化、伤口愈合以及纤维化均参与淋巴水肿发生发展。治疗性淋巴管生成和针对性炎症抑制可能有助于淋巴的结构和功能改善。
第二部分：预防和治疗方案
推荐意见六：专家组一致认为，在结合初始和随访评定的早期检出和监测计划前提下，许多减少风险行为的常规措施缺乏证据。使用患侧手臂进行静脉注射或测量血压并非禁忌证，尽管大多数患者较倾向于使用健侧手臂。个体化与一刀切的风险减少策略相比更为合理。
推荐意见七：专家组一致认为，临床医师应该鼓励有风险和已受累的淋巴水肿患者进行运动。抗阻运动（患者主动进行对抗阻力的运动方式，阻力可以来自器械或他人，以提高肌力和肌肉耐力）和有氧运动是安全的。乳腺癌相关淋巴水肿患者应与受过培训的淋巴水肿专业人士一起学习安全运动。
推荐意见八：专家组一致认为，腋窝逆行淋巴显影（ARM）和淋巴显微外科预防治疗方法（LYMPHA）预防手术策略现有数据令人鼓舞，应该对合适患者进行深入探索。鼓励参与即将开展的腋窝逆行淋巴显影（ARM）协作组研究。
推荐意见九：专家组一致认为，综合消肿疗法（CDT）是治疗的基础。有症状或测量变化的患者应该转诊进行淋巴水肿治疗评估、正式接受教育，并且根据国际淋巴学会（ISL）分期和个体表现提供分级干预。
推荐意见十：专家组一致认为，淋巴管-静脉吻合术（LVA）和吻合血管淋巴结移植（VLNT）对早期二级乳腺癌相关淋巴水肿可能有效。转诊是适当的，但是患者应该由了解淋巴水肿的多学科团队进行评定，并且接受包括手术在内的多种治疗计划。应该进行初始和随访评定，包括淋巴功能评定。长期负压淋巴脂肪抽吸对于保守治疗无效的严重晚期乳腺癌相关淋巴水肿有效。
相关阅读
Ann Surg Oncol. 2017 Oct;24(10):2818-2826.
Considerations for Clinicians in the Diagnosis, Prevention, and Treatment of Breast Cancer-Related Lymphedema: Recommendations from a Multidisciplinary Expert ASBrS Panel: Part 1: Definitions, Assessments, Education, and Future Directions.
McLaughlin SA, Staley AC, Vicini F, Thiruchelvam P, Hutchison NA, Mendez J, MacNeill F, Rockson SG, DeSnyder SM, Klimberg S, Alatriste M, Boccardo F, Smith ML, Feldman SM.
Mayo Clinic, Jacksonville, FL, USA; Patient Advocate, Akari Health, Boston, MA, USA; UCLA School of Medicine, Los Angeles, USA; Imperial College Healthcare, London, UK; Courage Kenny Rehabilitation Institute of AllinaHealth, Minneapolis, MN, USA; Miami Cancer Institute, Miami, FL, USA; Association of Breast Surgery Great Britain and Ireland, Royal College of Surgeons of England, London, UK; Stanford University School of Medicine, Stanford, CA, USA; The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Winthrop P. Rockefeller Cancer Institute, Little Rock, AR, USA; Lymphedema Alliance of New York, New York, NY, USA; S. Martino University Hospital, University of Genoa, Genoa, Italy; Hofstra Northwell School of Medicine, Lake Success, NY, USA; Montefiore Medical Center, The University Hospital for the Albert Einstein College of Medicine, New York, NY, USA.
Recommendation 1: The panel agrees that clinicians should establish a surveillance plan because early diagnosis leads to early treatment and increases the likelihood for limited disease burden.
Recommendation 2: The panel agrees that baseline and follow-up measurements of the ipsilateral and contralateral arms of all breast cancer patients are critical. All measurement techniques have advantages and disadvantages that should be considered when a comprehensive measurement strategy is developed that includes a combination of objective and subjective measures.
Recommendation 3: The panel agrees that clinicians should practice personalized medicine strategies to minimize axillary surgery, should question the routine use of postmastectomy or regional nodal irradiation, and should use genomic tests to guide the use of chemotherapy to collectively minimize the additive effects of multimodality therapy. Patients should maintain a healthy body weight/BMI.
Recommendation 4: The panel agrees that surgeons should admit and accept that lymphedema risks exist and educate themselves and their patients about these risks at preoperative and follow-up visits. Education should continue into survivorship and be incorporated into survivorship care plans.
Recommendation 5: To acknowledge the pathophysiology of lymphedema as a mechanical insufficiency alone is likely simplistic. Lymphatic obstruction, inflammation, immune response, complement activation, wound healing, and fibrosis to the development of lymphedema. Therapeutic lymphangiogenesis and targeted inflammatory inhibition may aid structural and functional lymphatic improvement.
PMID: 28766232
DOI: 10.1245/s10434-017-5982-4
Ann Surg Oncol. 2017 Oct;24(10):2827-2835.
Considerations for Clinicians in the Diagnosis, Prevention, and Treatment of Breast Cancer-Related Lymphedema, Recommendations from an Expert Panel: Part 2: Preventive and Therapeutic Options.
McLaughlin SA, DeSnyder SM, Klimberg S, Alatriste M, Boccardo F, Smith ML, Staley AC, Thiruchelvam PTR, Hutchison NA, Mendez J, MacNeill F, Vicini F, Rockson SG, Feldman SM.
Mayo Clinic, Jacksonville, FL, USA; The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Winthrop P. Rockefeller Cancer Institute, Little Rock, AR, USA; Lymphedema Alliance of New York, New York, NY, USA; S. Martino University Hospital, University of Genoa, Genoa, Italy; Northwell Health, Lake Success, NY, USA; Northwell Health Cancer Institute, Lake Success, NY, USA; Akari Health, Boston, MA, USA; Imperial College Healthcare, London, UK; Courage Kenny Rehabilitation Institute of AllinaHealth, Minneapolis, MN, USA; Miami Cancer Institute, Miami, FL, USA; Association of Breast Surgery Great Britain and Ireland, Royal College of Surgeons of England, London, UK; UCLA School of Medicine, Los Angeles, CA, USA; Stanford University School of Medicine, Stanford, CA, USA; Falk Cardiovascular Research Center, Stanford, CA, USA; Montefiore Medical Center, The University Hospital for the Albert Einstein College of Medicine, Montefiore Einstein Center for Cancer Care, New York, NY, USA.
Recommendation 6: The Panel agrees that within the context of an early detection/surveillance program incorporating baseline and follow-up assessments, the routine application of many risk-reducing behaviors is not supported. Use of the ipsilateral arm for IVs or blood pressures is not contraindicated, although most patients prefer to use the contralateral arm. Personalized risk-reduction strategies are more appropriate than blanket application of behaviors.
Recommendation 7: The Panel agrees that clinicians should encourage at-risk and affected lymphedema patients to exercise. Resistance and aerobic exercise is safe. Patients with BCRL should work with a trained lymphedema professional to learn to exercise safely.
Recommendation 8: The Panel agrees that emerging data on preventive surgical strategies with ARM and LYMPHA are promising and should be explored further with appropriate patients. Participation in the upcoming cooperative group study of ARM is encouraged.
Recommendation 9: The Panel agrees that CDT is the cornerstone of therapy. Patients with symptoms or measured changes should be referred for lymphedema therapy evaluation, formally educated, and provided with graduated intervention according to the International Society of Lymphology (ISL) staging and individual presentation.
Recommendation 10: The Panel agrees that LVA and VLNT may be effective for early secondary BCRL. Referral is appropriate, but patients should be assessed by a multidisciplinary team with an understanding of lymphedema and aftercare in which surgery is part of a multimodality treatment plan. Baseline and follow-up assessments should be made including functional lymphatic assessments. Lymphatic liposuction with long-term compression is effective for severe late-stage BCRL unresponsive to conservative management.
PMID: 28766218
DOI: 10.1245/s10434-017-5964-6
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