The Risk Factors of Lymphedema in Breast Cancer Patients Post Axillary Clearance

Introduction: Breast cancer is the number one malignancy affecting females in Saudi Arabia with a prevalence of 22.4%. Breast cancer incidence increases annually due to the aid of established screening programs, leading to the discovery of breast cancer in its early stages. Surgical treatment is an integral part of early breast cancer management to achieve local control. Axillary surgical interventions such sentinel lymph node biopsy (SLNB) and axillary lymph node clearance (ALND) aim to stage the axilla as an adjunct to the management of the primary breast tumor. In this paper, we reviewed female breast cancer patients aged 30 - 60 who underwent surgical treatment of SLNB and/or ALND with reporting the prevalence of lymphedema and other associated complications and risk factors. Methodology: A cross-sectional non-interventional study, with a sample size of 250 including breast cancer cases from 2016 to 2019 at National Guard Hospital (NGH) in Jeddah, Saudi Arabia. Results: A total of 253 breast cancer cases were included in this study, with a mean age of 53 years, 52.7% were postmenopausal and positive family history was present among 21% of cases. Further, 90.9% of the cases had unilateral disease. Staging was as follows: stage I 14.5%, stage II 45.2%, stage III 37.1%, and stage IV 3.2%. Mastectomy was done in 73.4% cases and lumpectomy was performed in 34.1% of cases. In addition, 93.3% of patients had SLNB and 49% of them were positive. Axillary dissection was performed in 69.6% of our patients. Radiotherapy and chemotherapy were given to 71.8% and 80.4% of cases respectively. Among the chemotherapy (chemo) recipients, 40.2% received adjuvant chemo, 54.5% received neoadjuvant chemo, and the remaining 5.3% received both. Further, the most prevalent complication was pain accounting for 42.1% of total complications, and the least prevalent was cellulitis 4%. Also, seroma developed in 18.3% cases, paresthesia noted in 5.6% of cases, winged scapula was reported as 2%, weakness and necrosis were seen in 6% and 13.1% of cases respectively. Axillary vein thrombosis and lymphangiosarcoma were reported in none of the patients (0%). Lymphoedema accounted for 16.1% of overall complications, 85% of the patients who developed lymphedema had undergone ALND, and 12.9% and 14.4% received radiotherapy and chemotherapy respectively. Lymphedema was observed in breast cancer stages as follows: stage I 1.2%, stage II 7.2%, and stage III 5.2%. Patients with body mass index (BMI) of 30 - 39 kg/m2 had 7.2% prevalence of lymphedema compared to other BMI groups. Overall mortality was 8.3%. Conclusion: The findings of our study suggest that the prevalence of lymphedema was higher in ALND patients with locally advanced tumors, and higher BMI, compared to patients with stage I breast cancer and low BMI. Further, the prevalence of lymphedema in patients who underwent ALND was significantly lower than those who were treated by lumpectomy 10.3% (p-value = 0.034) in comparison to mastectomy 19.3%.

Herlyn-Werner-Wunderlich Syndrome Presenting with Abdominal Pain: A Case Report

Herlyn-Werner-Wunderlich (HWW) syndrome is a rare congenital anomaly characterized by triad of uterus didelphys, obstructed hemi vagina, and ipsilateral renal agenesis. The most common presentation is abdominal pain, dysmenorrhea, and abdominal mass secondary to hemi-hematometrocolpos. We report an emergency presentation of this syndrome during the pandemic of COVID-19 in Qatif Central Hospital, Saudi Arabia, April 2020. An 11-year-old Saudi girl presented to the emergency room with three months history of cyclical lower abdominal pain. The pain was progressive, continuous and not relieved by analgesics. Abdominal examination revealed a tender abdominal mass mainly in the left iliac fossa, Ultrasound evaluation showed two uterine bodies. The left uterus was distended with complex fluid. Pelvic MRI findings consistent with Herlyn-Werner-Wunderlich (HWW) syndrome were found with uterine didelphys and left sided hematometra resulting from obstructed hemi-vagina and ipsilateral agenesis of the left kidney. Resection of the vaginal septum and drainage of hematometra was done. The patient recovered with normal cyclical menstruation. Cyclical or continuous lower abdominal pain with or without amenorrhea is the usual presentation of HWW syndrome during adolescence. Diagnosis is made by ultrasonography and MRI. Early diagnosis and accurate management can provide pain relief, prevent future complications, and preserve fertility.