Hot of the Press August 2020

We have collated some great articles and material published over the last month. Click on the links below to read the abstract or download the full paper.

Anatomy / Physiology /Pathophysiology

New Insights into the Pathophysiology of Primary and Secondary Lymphedema: Histopathological Studies on Human Lymphatic Collecting Vessels - click for abstract

New Insights into the Pathophysiology of Primary and Secondary Lymphedema: Histopathological Studies on Human Lymphatic Collecting Vessels

Barone V, Borghini A, Tedone Clemente E, Aglianò M, Gabriele G, Gennaro P, Weber E. Lymphat Res Biol. 2020 Jul 20

Lymphedema is characterized by an accumulation of interstitial fluids due to inefficient lymphatic drainage. Primary lymphedema is a rare condition, including congenital and idiopathic forms. Secondary lymphedema is a common complication of lymph node ablation in cancer treatment. Previous studies on secondary lymphedema lymphatic vessels have shown that after an initial phase of ectasia, worsening of the disease is associated with wall thickening accompanied by a progressive loss of the endothelial marker podoplanin. Methods and Results: We enrolled 17 patients with primary and 29 patients with secondary lymphedema who underwent lymphaticovenous anastomoses surgery. Histological sections were stained with Masson’s trichrome, and immunohistochemistry was performed with antibodies to podoplanin, smooth muscle α-actin (α-SMA), and myosin heavy chain 11 (MyH11). In secondary lymphedema, we found ectasis, contraction, and sclerosis vessel types. In primary lymphedema, the majority of vessels were of the sclerosis type, with no contraction vessels. In both primary and secondary lymphedema, not all α-SMA-positive cells were also positive for MyH11, suggesting transformation into myofibroblasts. The endothelial marker podoplanin had a variable expression unrelatedly with the morphological vessel type. Conclusions: Secondary lymphedema collecting vessels included all the three types described in literature, that is, ectasis, contraction, and sclerosis, whereas in primary lymphedema, we found the ectasis and the sclerosis but not the contraction type. Some cells in the media stained positively for α-SMA but not for MyH11. These cells, possibly myofibroblasts, may contribute to collagen deposition.

Prevalence and Risk Factors

Weight management barriers and facilitators after breast cancer in Australian women: a national survey - click for abstract

Weight management barriers and facilitators after breast cancer in Australian women: a national survey

Carolyn Ee1* , Adele Elizabeth Cave1, Dhevaksha Naidoo1, Kellie Bilinski1 and John Boyages2. BMC Women’s Health (2020) 20:140.

Background: Breast cancer is the most common cancer in women worldwide. Weight gain after breast cancer is associated with poorer health outcomes. The aim of this study was to describe how Australian breast cancer survivors are currently managing their weight.

Methods: Online cross-sectional survey open to any woman living in Australia who self-identified as having breast cancer, between November 2017 and January 2018.

Results: We received 309 responses. Most respondents described their diet as good/excellent and reported moderate-high levels of weight self-efficacy. Despite this, the proportion of overweight/obesity increased from 47% at time of diagnosis to 67% at time of survey. More than three quarters of respondents did not receive any advice on weight gain prevention at the time of diagnosis. 39% of women reported being less active after cancer diagnosis, and and few weight loss interventions were perceived to be effective. Facilitators were structured exercise programs, prescribed diets, and accountability to someone else, while commonly cited barriers were lack of motivation/willpower, fatigue, and difficulty maintaining weight. Women who cited fatigue as a barrier were almost twice as likely to be doing low levels of physical activity (PA) or no PA than women who did not cite fatigue as a barrier.

Conclusions: We report high levels of concern about weight gain after BC and significant gaps in service provision around weight gain prevention and weight management. Women with BC should be provided with support for weight gain prevention in the early survivorship phase, which should include structured PA and dietary changes in combination with behavioural change and social support. Weight gain prevention or weight loss programs should address barriers such as fatigue. More research is required on the effectiveness of diet and exercise interventions in BC survivors, particularly with regard to weight gain prevention.

Body Mass Index and Lymphedema Morbidity: Comparison of Obese versus Normal-Weight Patients - click for abstract

Body Mass Index and Lymphedema Morbidity: Comparison of Obese versus Normal-Weight Patients

Greene AK, Zurakowski D, Goss JA. Plast Reconstr Surg. 2020 Aug;146(2):402-407

BACKGROUND: Obesity is a risk factor for the development of secondary lymphedema after axillary lymphadenectomy and radiation therapy. The purpose of this study was to determine whether obesity influences the morbidity of lymphedema in patients who have the condition.

METHODS: Two cohorts of patients were compared: group 1, normal weight (body mass index ≤25 kg/m); and group 2, obese (body mass index ≥30 kg/m). Inclusion criteria were patients aged 21 years or older with lymphedema confirmed by lymphoscintigraphy. Covariates included age, sex, lymphedema type (primary or secondary), location, comorbidities, lymph node dissection, radiation therapy, lymphoscintigram result, and disease duration. Outcome variables were infection, hospitalization, and degree of limb overgrowth. The cohorts were compared using the Mann-Whitney U test, Fisher’s exact test, and multivariable logistic regression.

RESULTS: Sixty-seven patients were included: group 1, n = 33; and group 2, n = 34. Disease duration did not differ between groups (p = 0.72). Group 2 was more likely to have an infection (59 percent), hospitalization (47 percent), and moderate or severe overgrowth (79 percent), compared to group 1 (18, 6, and 40 percent, respectively; p < 0.001). Multivariable logistic regression showed that obesity was an independent risk factor for infection (OR, 7.9; 95 percent CI, 2.5 to 26.3; p < 0.001), hospitalization (OR, 30.0; 95 percent CI, 3.6 to 150.8; p < 0.001), and moderate to severe limb overgrowth (OR, 6.7; 95 percent CI, 2.1 to 23.0; p = 0.003). CONCLUSIONS: Obesity negatively affects patients with established lymphedema. Obese individuals are more likely to have infections, hospitalizations, and larger extremities compared to subjects with a normal body mass index. Patients with lymphedema should be counselled about the negative effects of obesity on their condition.

Comparing the prevalence, location, and severity of head and neck lymphedema after postoperative radiotherapy for oral cavity cancers and definitive chemoradiotherapy for oropharyngeal, laryngeal, and hypopharyngeal cancers - click for abstract

Jeans C, Brown B, Ward EC, Vertigan AE, Pigott AE, Nixon JL, Wratten C, Fellowship: Royal Australian and New Zealand College of Radiologists. Head Neck. 2020 Jul 31

BACKGROUND: This study aimed to examine the prevalence, location, and severity of chronic internal, external, and combined head and neck lymphedema (HNL) in patients with head and neck (HNC) who were treated with definitive chemoradiotherapy (CRT) or postoperative radiotherapy (PORT).

METHODS: Sixty-two participants between 1 and 3 years post-treatment were recruited. Internal HNL was rated with Patterson’s Scale. External HNL was graded with the MD Anderson Cancer Center Lymphedema Rating Scale.

RESULTS: Ninety-eight percent of participants presented with some form of chronic HNL. Sixty-one percent had internal HNL only, 35% had combined HNL, and 2% had external HNL only. Participants treated with PORT were more likely to experience combined HNL (69% vs 24%, P = .001), whereas those treated with CRT were more likely to have internal HNL only (74% vs 25%, P = .001).

CONCLUSIONS: Chronic HNL is highly prevalent following multimodal treatment, and differences in HNL presentations exist between treatment modalities.

Incidence of lymphedema in the lower limbs and lymphocyst formation within one year of surgery for endometrial cancer: A prospective longitudinal multicenter study - click for abstract

Incidence of lymphedema in the lower limbs and lymphocyst formation within one year of surgery for endometrial cancer: A prospective longitudinal multicenter study

Wedin M, Stålberg K, Marcickiewicz J, Ahlner E, Åkesson Å, Lindahl G, Kjølhede P, LASEC study group. Gynecol Oncol. 2020 Aug 03

OBJECTIVE: The study aimed to determine the incidence of lower limb lymphedema (LLL) after surgery for endometrial cancer (EC) by means of three methods, and to determine the incidence of lymphocysts after one year.

METHODS: A prospective longitudinal multicenter study was conducted in 14 hospitals in Sweden. Two-hundred-and-thirty-five women with EC were included; 116 underwent surgery that included lymphadenectomy (+LA) and 119 were without lymphadenectomy (-LA). Lymphedema was assessed objectively on four occasions; preoperatively, at 4-6 weeks, six months and one year postoperatively using systematic measurement of leg circumferences, enabling calculation of leg volumes, and a clinical grading of LLL, and subjectively by the patient’s perception of lymphedema measured by a lymphedema-specific quality-of-life instrument. Lymphocyst was evaluated by vaginal ultrasonography.

RESULTS: After one year the incidence of LLL after increase in leg volume adjusted for body mass index was 15.8% in +LA women and 3.4% in -LA women. The corresponding figures for clinical grading were 24.1% and 11.8%, and for patient-reported perceived LLL 10.7% and 5.1%. The agreement between the modalities revealed fair to moderate correlation between patient-reported LLL and clinical grading, but poor agreement between volume increase and patient-reported LLL or clinical grading. Lymphocysts were found in 4.3% after one year.

CONCLUSIONS: Although the incidence of LLL and lymphocysts after surgery for EC including LA seemed to be relatively high the study demonstrated significant variations in incidence depending on the measurement modality. This emphasizes the need for a ‘gold standard’ of measurement of LLL in clinical practice and research.

Assessment

Bioimpedance Analysis for Predicting Outcomes of Complex Decongestive Therapy for Gynecological Cancer Related Lymphedema: A Feasibility Study - click for abstract

Bioimpedance Analysis for Predicting Outcomes of Complex Decongestive Therapy for Gynecological Cancer Related Lymphedema: A Feasibility Study

Bae SH, Kim WJ, Seo YJ, Kim J, Jeon JY. Ann Rehabil Med. 2020 Jun;44(3):238-245

OBJECTIVE: To determine whether the bioimpedance analysis (BIA) ratios of upper to lower extremities could predict treatment outcomes after complex decongestive therapy (CDT) for gynecological cancer related lymphedema (GCRL).

METHODS: A retrospective study, from March 2015 to December 2018, was conducted. The study sample comprised patients receiving CDT, 30 minutes per day, for 10 days. Bioimpedance was measured pre- and post-CDT. Circumference measurements were obtained at 20 and 10 cm above the knee (AK) and 10 cm below the knee (BK). We calculated the expected impedance at 0 Hz (R0) of extremities and upper/lower extremity R0 ratios (R0U/L). We evaluated the relationship between R0U/L and changes in R0U/L and circumferences, pre- and post-CDT.

RESULTS: Overall, 59 patients were included in this study. Thirty-one lower extremities in 26 patients comprised the acute group, and 38 lower extremities in 33 patients comprised the chronic group. Pre-treatment R0U/L was significantly correlated with R0U/L change after adjusting for age and BMI (acute: R=0.513, p<0.01; chronic: R=0.423, p<0.01). In the acute group, pre-treatment R0U/L showed a tendency to be correlated with circumference change (AK 20 cm: R=0.427, p=0.02; AK 10 cm: R=0.399, p=0.03). CONCLUSION: Our study results suggested that pre-treatment BIA could predict volume reductions after CDT in the early stages of GCRL. These findings implied that BIA value could be one possible parameter to apply in treatment outcomes prediction, during the early stage of GCRL. Therefore, further large-scale prospective studies will be beneficial.

Bioimpedance spectroscopy and volumetry in the immediate/short-term monitoring of intensive complex decongestive treatment of lymphedema - click for abstract

Bioimpedance spectroscopy and volumetry in the immediate/short-term monitoring of intensive complex decongestive treatment of lymphedema.

Cavezzi A, Urso SU, Paccasassi S, Mosti G, Campana F, Colucci R. Phlebology. 2020 Jul 06

AIMS: To assess (a) immediate/short-term outcomes of intensive complex decongestive treatment of lower limb lymphedema, by means of bioimpedance spectroscopy and tape measurement-based volumetry, and (b) correlation between these two methods.

PATIENTS AND METHODS: Cohort study on patients affected by unilateral primary or secondary lymphedema, stage II or III. Patients underwent complex decongestive treatment (manual and electro-sound lymphatic drainage, compression bandage, exercises, low-carb nutrition, and dietary supplements) for six days. Before (D0), three and six days after complex decongestive treatment (D3 and D6), volumetry and bioimpedance spectroscopy data of the total limb and lower leg were collected. Statistical analysis was applied to pre-post treatment outcomes and to the volumetry/bioimpedance spectroscopy correlation.

RESULTS: Forty-one patients (15 males and 26 females, mean age: 50.7 years) were included. A progressive improvement of volumetry and bioimpedance spectroscopy figures was recorded. Total limb and leg volumetry (mean value in cc) was, respectively, 11,072.9 and 3150.8 at D0, 10,493 (-5.2%, p = 0.001) and 2980.2 (-5.4%, p < 0.001) at D6. Total limb lymphatic index at D0 and D6 was 18.9 and 14.8 (-21.5%, p < 0.001). Total limb resistance at D0, D3, and D6 was 200.4, 225.7, and 237.5 (+18.5%, p < 0.001), respectively; leg resistance at D0 and D6 was 117.5 and 150 (+27.7%, p < 0.001), respectively. Total limb reactance at D0, D3, and D6 was 12.2, 15, and 16.6 (+35.5%, p < 0.001), respectively. Leg reactance at D0 and D6 was 7.7 and 11.5 (+ 49.6%, p < 0001), respectively. Correlation volumetry/bioimpedance spectroscopy data were (a) total limb volumetry/resistance rho = -0.449, p < 0.01; volumetry/reactance rho=-0.466, p < 0.01; volumetry/lymphatic index rho = 0.581, p < 0.01; (b) leg volumetry/resistance rho=-0.579, p < 0.01; volumetry/reactance rho=-0.469, p < 0.01; volumetry/lymphatic index rho = 0.466, p < 0.05. CONCLUSIONS: Complex decongestive treatment on lymphedematous limbs was effective at short term; both volumetry and bioimpedance spectroscopy showed a statistically significant improvement. Resistance and reactance increase, with lymphatic index decrease, correlated with volumetry decrease. Bioimpedance spectroscopy proved to help to assess fluid decrease and the tissue-related parameters variations.

Clinical and Scintigraphic Predictors of Primary Lower Limb Lymphedema-Volume Reduction During Complete Decongestive Physical Therapy - click for abstract

Clinical and Scintigraphic Predictors of Primary Lower Limb Lymphedema-Volume Reduction During Complete Decongestive Physical Therapy.

Vignes S, Simon L, Benoughidane B, Simon M, Fourgeaud C. Phys Ther. 2020 05 18;100(5):766-772

BACKGROUND: Primary lower limb lymphedema is a chronic debilitating disorder without curative treatment. The initial treatment phase is dedicated to reducing lymphedema volume, whereas the second aims to stabilize that volume.

OBJECTIVE: The objective of this study was to analyze clinical and lymphoscintigraphic characteristics during complete decongestive physical therapy as predictors of primary unilateral lower limb lymphedema-volume reduction. DESIGN: This observational, retrospective study included 222 consecutive patients (January 2009-January 2017; median age: 45.8 years) with lymphedema affecting the entire lower limb, who received complete decongestive physical therapy for the first time in a specialized lymphedema management center.

METHODS: Complete decongestive physical therapy consisted of low-stretch bandaging, manual lymph drainage, exercises, and skin care for all patients. Lymphoscintigraphy preceded treatment.

RESULTS: Median lymphedema evolution was 73 months, and median excess volume was 34%. Median (interquartile range) lymphedema volumes were 2845 (1038-3487) mL before and 1276 (601-2195) mL after a median of 11 days of complete decongestive physical therapy, with 34% median reduction. Multivariate analyses retained age, body mass index >40 kg/m2, and previous cellulitis, as independently associated with lymphedema volume reduction. For each additional year of age, volume reduction increased 0.16%. Unexpectedly, log-transformed initial lymphedema volumes indicated a negative impact, that is, 4.95%, for each log-unit gain. Patients with previous cellulitis episode(s) obtained 6.9% and those with BMI >40 kg/m2 17.1% higher lymphedema volume reductions. Lower limb lymphoscintigraphy was available for 150 (67.6%) patients. Having dermal back flow was associated with greater lymphedema volume reduction than not (respectively, 39% vs 31%).

LIMITATIONS: This study was retrospective, and only 67.6% of patients underwent lymphoscintigraphy.

CONCLUSION: Our analysis identified clinical and scintigraphic predictors of primary lymphedema volume reduction for patients with unilateral disease. Lymphoscintigraphy helps confirm lymphedema and predict volume reduction. Further study is required to confirm these observations.

Cross-sectional validity and specificity of comprehensive measurement in lymphedema and lipedema of the lower extremity: a comparison of five outcome instruments

Angst F, Lehmann S, Aeschlimann A, Sandòr PS, Wagner S. Health Qual Life Outcomes. 2020 Jul 22;18(1):245

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Quantifying the Impact of Axillary Surgery and Nodal Irradiation on Breast Cancer-Related Lymphedema and Local Tumor Control: Long-Term Results From a Prospective Screening Trial - click for abstract

Quantifying the Impact of Axillary Surgery and Nodal Irradiation on Breast Cancer-Related Lymphedema and Local Tumor Control: Long-Term Results From a Prospective Screening Trial

Naoum GE, Roberts S, Brunelle CL, Shui AM, Salama L, Daniell K, Gillespie T, Bucci L, Smith BL, Ho AY, Taghian AG. J Clin Oncol. 2020 Jul 30

PURPOSE: To independently evaluate the impact of axillary surgery type and regional lymph node radiation (RLNR) on breast cancer-related lymphedema (BCRL) rates in patients with breast cancer.

PATIENTS AND METHODS: From 2005 to 2018, 1,815 patients with invasive breast cancer were enrolled in a lymphedema screening trial. Patients were divided into the following 4 groups according to axillary surgery approach: sentinel lymph node biopsy (SLNB) alone, SLNB+RLNR, axillary lymph node dissection (ALND) alone, and ALND+RLNR. A perometer was used to objectively assess limb volume. All patients received baseline preoperative and follow-up measurements after treatment. Lymphedema was defined as a ≥ 10% relative increase in arm volume arising > 3 months postoperatively. The primary end point was the BCRL rate across the groups. Secondary end points were 5-year locoregional control and disease-free-survival.

RESULTS: The cohort included 1,340 patients with SLNB alone, 121 with SLNB+RLNR, 91 with ALND alone, and 263 with ALND+RLNR. The overall median follow-up time after diagnosis was 52.7 months for the entire cohort. The 5-year cumulative incidence rates of BCRL were 30.1%, 24.9%, 10.7%, and 8.0% for ALND+RLNR, ALND alone, SLNB+RLNR, and SLNB alone, respectively. Multivariable Cox models adjusted for age, body mass index, surgery, and reconstruction type showed that the ALND-alone group had a significantly higher BCRL risk (hazard ratio [HR], 2.66; P = .02) compared with the SLNB+RLNR group. There was no significant difference in BCRL risk between the ALND+RLNR and ALND-alone groups (HR, 1.20; P = .49) and between the SLNB-alone and SLNB+RLNR groups (HR, 1.33; P = .44). The 5-year locoregional control rates were similar for the ALND+RLNR, ALND-alone, SLNB+RLNR, and SLNB-alone groups (2.8%, 3.8%, 0%, and 2.3%, respectively).

CONCLUSION: Although RLNR adds to the risk of lymphedema, the main risk factor is the type of axillary surgery used

Indocyanine Green Lymphography and Lymphoscintigraphy Severity Stage Showed Strong Correlation in Lower Limb Lymphedema - click for abstract

Indocyanine Green Lymphography and Lymphoscintigraphy Severity Stage Showed Strong Correlation in Lower Limb Lymphedema.

Yoon JA, Shin MJ, Kim JH. Lymphat Res Biol. 2020 Jul 27

To examine the correlation between lymphedema severity on lymphoscintigraphy and indocyanine green (ICG) lymphography in patients with secondary lower extremity lymphedema. Methods and Results: The maximal circumference difference (MCD) between the two legs was recorded. Lymphoscintigraphy and ICG lymphography images were classified into type I to V according to dermal backflow (DB) stage and MD Anderson Cancer Center (MDACC) stage based on lymphatic flow preservation and how DB was extended. Correlation between the scales was analyzed. Forty-four patients attended our hospital for evaluation of secondary lower extremity lymphedema. The most common cause of lymphedema was a postoperative complication of a malignant tumor (32 patients; 72.5%). Correlation analysis showed that lymphoscintigraphy and ICG DB (anterior) stage (r = 0.92), lymphoscintigraphy and ICG DB (posterior) stage (r = 0.94), and lymphoscintigraphy and MDACC stage (r = 0.93) exhibited very strong positive correlations. Intrarater agreement between lymphoscintigraphy and ICG DB (posterior) stage was substantial (κ = 0.65), and moderate between lymphoscintigraphy and ICG DB (anterior) stage (κ = 0.59) and lymphoscintigraphy and MDACC stage (κ = 0.52). Lymphedema severity stages and MCDs exhibited moderate positive correlations. Conclusion: Lymphoscintigraphy and ICG lymphography stage were strongly and positively correlated. These studies can work synergistically as complementary studies of lymphedema severity.

Use of magnetic resonance imaging for evaluation of therapeutic response in breast cancer-related lymphedema: A systematic review - click for abstract

Use of magnetic resonance imaging for evaluation of therapeutic response in breast cancer-related lymphedema: A systematic review.

Forte AJ, Boczar D, Kassis S, Huayllani MT, McLaughlin SA. Arch Plast Surg. 2020 Jul;47(4):305-309

Breast cancer treatment-related lymphedema (BCRL) is a common comorbidity in breast cancer survivors. Although magnetic resonance imaging (MRI) is widely used to evaluate therapeutic response of patients with various medical conditions, it is not routinely used to evaluate lymphedema patients. We conducted a systematic review of the literature to identify studies on the use of MRI to evaluate therapy for BCRL. We hypothesized that MRI could provide information otherwise not possible through other examinations. On October 21, 2019, we conducted a systematic review on the PubMed/MEDLINE and Scopus databases, without time frame or language limitations, to identify studies on the use of MRI to evaluate therapy for BCRL. We excluded studies that investigated other applications of MRI, such as lymphedema diagnosis and surgical planning. Of 63 potential articles identified with the search, three case series fulfilled the eligibility criteria. In total, 53 patients with BCRL were included and quantitatively evaluated with MRI before and after manual lymphatic drainage. Authors used MRI or MR lymphagiography to investigate factors such as lymphatic vessel cross-sectional area, tissue water relaxation time (T2), and chemical exchange saturation transfer. The only study that compared MRI measurement with standard examinations reported that MRI added information to the therapy evaluation. MRI seems to be a promising tool for quantitative measurement of therapeutic response in patients with BCRL. However, the identified studies focused on only manual lymphatic drainage and were limited by the small numbers of patients. More studies are necessary to shed light on the topic.

Development of the Breast Cancer Related Lymphedema Self-Care Scale - click for abstract

Development of the Breast Cancer Related Lymphedema Self-Care Scale.

Deveci Z, Karayurt Ö, Bilik O, Eyigör S. Clin Nurs Res. 2020 Aug 06

The purpose of study was to develop the Breast Cancer Related Lymphedema Self-Care Scale to evaluate the self-care practices of women with breast cancer-related lymphedema (BRCL); and to examine the psycholinguistic and psychometric characteristics of this scale. The item pool of the scale was created based on the literature in this descriptive study. Content validity, explanatory and confirmatory factor analyses used in evaluation of the validity; and item analyzes, the Cronbach’s Alpha and Split Half analyzes were made for reliability in the study. The content validity index was found to be above 0.80. In the Explanatory Factor Analysis, a four-factor structure was obtained. In Confirmatory Factor Analysis, fit indices were found to be acceptable. Cronbach’s Alpha coefficients of the sub-dimensions of the scale varied between 0.62 and 0.86. It was determined the Breast Cancer Related Lymphedema Self-Care Scale was a valid and reliable scale for women with BRCL.

Management Strategies

Water Reductive Effect of Lymphaticovenular Anastomosis on Upper-Limb Lymphedema: Bioelectrical Impedance Analysis and Comparison with Lower-Limb Lymphedema - click for abstract

Water Reductive Effect of Lymphaticovenular Anastomosis on Upper-Limb Lymphedema: Bioelectrical Impedance Analysis and Comparison with Lower-Limb Lymphedema

Yasunaga Y, Yanagisawa D, Nakajima Y, Mimura S, Kobayashi M, Yuzuriha S, Kondoh S

J Reconstr Microsurg. 2020 Jul 13

Background: We previously examined the water reductive effect of lymphaticovenular anastomosis (LVA) using bioelectrical impedance analysis (BIA) measurement on lower-limb lymphedema and revealed mean water volume reduction and edema reduction rate by leg LVA to be 0.86 L and 45.1%, respectively. This study aimed to clarify the water reductive effect of LVA on arm lymphedema and compare its results with those for leg lymphedema.

Patients and methods: The efficacy of LVA for unilateral arm lymphedema was evaluated using BIA in a retrospective cohort. Limb circumference and arm body water volume (ABW) of the affected and unaffected arms were measured before and after LVA. Mean water volume reduction (ΔABW) and edema reduction rate by arm LVA were compared with values for leg LVA cited from our previous report as a historical control.

Results: Nineteen consecutive patients were enrolled. The mean ΔABW and edema reduction rate by BIA were 0.267 L and 46.0%, respectively. The decreasing rate of ABW by BIA was significantly larger than those of the upper extremity lymphedema index and sum of 5 circumferences measurement methods. ΔABW could be predicted by a regression line based on the preoperative water volume difference between affected and unaffected limbs. The mean edema reduction rates for arm and leg LVA were comparable.

Conclusion: The water reductive effect of LVA on upper-limb lymphedema was demonstrated by BIA assessment. BIA can reflect the effect of LVA more sensitively than conventional objective measurements and may facilitate the interpretation of LVA results. Although water volume reduction by arm LVA was less than that by leg LVA, the edema reduction rates were comparable.

The results of the intensive phase of complete decongestive therapy and the determination of predictive factors for response to treatment in patients with breast cancer related-lymphedema. - click for abstract

The results of the intensive phase of complete decongestive therapy and the determination of predictive factors for response to treatment in patients with breast cancer related-lymphedema.

Keskin D, Dalyan M, Ünsal-Delialioğlu S, Düzlü-Öztürk Ü. Cancer Rep (Hoboken). 2020 Apr;3(2)

BACKGROUND: Lymphedema is a common complication of breast cancer or its treatment. The gold standard treatment for lymphedema is complete decongestive therapy. There are few studies about the predictive factors for the effectiveness of complete decongestive therapy.

AIM: To evaluate the results of the intensive phase of complete decongestive therapy, and to determine the predictive factors for the response to treatment in patients with breast cancer-related lymphedema.

METHODS AND RESULTS: Fifty-seven patients with breast cancer-related lymphedema (mean age: 56.2 ± 11.2 years) who underwent complete decongestive therapy between 2014 and 2016 were evaluated retrospectively. Extremity volume was calculated using circumferential measurements and the truncated cone formula technique. Response to treatment was evaluated using the percentage reduction of excess volume formula, which was obtained by calculating the extremity volume before and after treatment. The median percentage reduction of excess volume was 27.7% (IQR,13.6-50.3). The history of skin infection was related to lower percentage reduction of excess volume (P = 0.001). Although percentage reduction of excess volume was positively correlated with education level (r = 0.286, P = 0.031), percentage reduction of excess volume was negatively correlated with lymphedema duration (r = -0.361, P = 0.006), postoperative duration (r = -0.314, P = 0.018), percentage of excess volume (r = -0.398, P = 0.002), and number of complete decongestive therapy sessions (r = -0.436, P = 0.001). Univariate and multivariate analyses showed that the independent variables for percentage reduction of excess volume were percentage of excess volume (P = 0.009) and education level (P = 0.021).

CONCLUSION: Complete decongestive therapy is an effective method in patients with breast cancer related-lymphedema. The most important predictive factors for the efficacy of treatment were found as percentage of excess volume and education level. Patients with breast cancer should be followed up regularly and receive complete decongestive therapy in the early stage of lymphedema

Clinical and Scintigraphic Predictors of Primary Lower Limb Lymphedema-Volume Reduction During Complete Decongestive Physical Therapy - click for abstract

Clinical and Scintigraphic Predictors of Primary Lower Limb Lymphedema-Volume Reduction During Complete Decongestive Physical Therapy.

Vignes S, Simon L, Benoughidane B, Simon M, Fourgeaud CPhys Ther. 2020 05 18;100(5):766-772

DESIGN: This observational, retrospective study included 222 consecutive patients (January 2009-January 2017; median age: 45.8 years) with lymphedema affecting the entire lower limb, who received complete decongestive physical therapy for the first time in a specialized lymphedema management center.

METHODS: Complete decongestive physical therapy consisted of low-stretch bandaging, manual lymph drainage, exercises, and skin care for all patients. Lymphoscintigraphy preceded treatment.

LIMITATIONS: This study was retrospective, and only 67.6% of patients underwent lymphoscintigraphy.

Lymphedema Prevention Surgery: Improved Operating Efficiency Over Time - click for abstract

Lymphedema Prevention Surgery: Improved Operating Efficiency Over Time

Shaffer K, Cakmakoglu C, Schwarz GS, ElSherif A, Al-Hilli Z, Djohan R, Radford DM, Grobmyer S, Bernard S, Moreira A, Fanning A, Tu C, Valente SA. Ann Surg Oncol. 2020 Jul 27

BACKGROUND: Lymphedema prevention surgery (LPS), which identifies, preserves, and restores lymphatic flow via lymphaticovenous bypasses (LVB), has demonstrated potential to decrease lymphedema in breast cancer patients requiring axillary lymph node dissection. Implementing this new operating technique requires additional operating room (OR) time and coordination. This study sought to evaluate the improvement of LPS technique and OR duration over time.

METHODS: A prospective database of patients who underwent LPS at our institution from 2016 to 2019 was queried. Type of breast and reconstruction surgery, number of LVB performed, and OR times were collected. LPS details were compared by surgical group and year performed.

RESULTS: Ninety-four patients underwent LPS, and 88 had complete OR time data available for analysis. Average age was 51 years, body mass index of 28, with an average of 15 lymph nodes removed. Reconstructive treatment groups included prosthetic reconstruction 56% (49), oncoplastic reduction 10% (9), and no reconstruction 34% (30). The number of patients undergoing LPS increased significantly from 2016 to 2019, and average number of LVB per patient doubled. In patients without reconstruction, the average time for LPS improved significantly from 212 to 87 min from 2016 to 2019 (p = 0.015) and similarly in patients undergoing LPS with prosthetic reconstruction from 238 to 160 min (p = 0.022).

CONCLUSIONS: LVB is an emerging surgical lymphedema prevention technique. While requiring additional surgical time, our results show that with refinement of technique, over 4 years, we were able to perform double the number of LVB per patient in half the OR time

Conserving the lymphatics from the arm using fluorescence imaging in patients with breast cancer at high risk of postoperative lymphedema: a pilot study - click for abstract

Conserving the lymphatics from the arm using fluorescence imaging in patients with breast cancer at high risk of postoperative lymphedema: a pilot study

Yoon KH, Lim SM, Koo B, Kim JY, Park HS, Park S, Kim SI, Park BW, Cho YU. Gland Surg. 2020 Jun;9(3):629-636

Postoperative lymphedema in breast cancer survivors is a serious complication that develops from axillary lymph node dissection (ALND), chemotherapy, and radiation therapy. Axillary reverse mapping (ARM) was recently introduced to reduce lymphedema. This pilot study aimed to investigate the feasibility of preserving the ARM node using fluorescence imaging for patients at high risk of lymphedema.

Methods: We prospectively screened patients with breast cancer who had pathologic node-positive disease at diagnosis and were scheduled for neoadjuvant chemotherapy (NCT). The sentinel lymph node (SLN) was identified using blue dye and radioisotope, while the ARM node was traced using indocyanine green (ICG). In cases in which SLN was negative on the intraoperative frozen section examination, the ARM node and lymphatics were preserved.

Results: Of the 20 screened patients, six whose metastatic axillary lymph node (ALN) was converted to clinically node-negative disease after NCT were enrolled. No patients experienced recurrence at 24 months postoperative. Four patients who had a preserved ARM node did not develop lymphedema. One patient whose ARM node was not preserved due to SLN identification failure did not develop postoperative lymphedema. One patient who underwent ALND without ARM node conservation because of metastatic SLN on frozen section examination developed postoperative lymphedema.

Conclusions: ARM is oncologically safe, decreases the incidence of postoperative lymphedema, and allows for the early detection of postoperative lymphedema in patients who underwent ALND. Ultimately, ARM may help improve the quality of life of patients with pathologic node-positive breast cancer.