Hot of the Press October 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

Periclavicular Lymph Node Activation Maintains the Lymphatic Circulation of Upper Extremity Following Breast Cancer Surgery with Axillary Lymph Node Dissection

Su Hwan Kang, MD,1 and Dong Gyu Lee, MD, PhD2. Lymphatic Research Biology, 2020.

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Prevalence and Risk Factors

Influences of lower limb edema on daily lives of elderly individuals in an elderly day care center

Sayumi Tsuchiya1, Takuto Sawazaki2, Shuji Osawa3,4, Makoto Fujiu3, Mayumi Okuwa5, Junko Sugama5,6. Jpn J Nurs Sci. 2020.

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A systematic review of magnetic resonance lymphography for the evaluation of peripheral lymphedema - click for abstract

A systematic review of magnetic resonance lymphography for the evaluation of peripheral lymphedema

Renée M. L. Miseré, MD,a Joost A. G. N. Wolfs, MD,a Marc B. I. Lobbes, MD, PhD,b,c,d
René R. W. J. van der Hulst, MD, PhD,a and Shan S. Qiu, MD, PhD.  Journal of Vascular Surgery: Venous and Lymphatic Disorders . Volume 8, Number 5.

Objective: Visualization of the lymphatic system is necessary for both early diagnosis and associated treatments. A promising imaging modality is magnetic resonance lymphography (MRL). The aim of this review was to summarize different MRL protocols, to assess the clinical value in patients with peripheral lymphedema, and to define minimal requirements necessary for visualization of lymphatics.

Methods: A systematic literature search was conducted in PubMed, Embase, and the Cochrane Library in December 2018. Studies performing MRL in patients with peripheral lymphedema or healthy participants were included. Study design, population, etiology, duration of lymphedema, clinical staging, contrast agent, dose, injection site, and technical magnetic resonance imaging details were analyzed. No meta-analyses were performed because of different study aims and heterogeneity of the study populations.

Results: Twenty-five studies involving 1609 patients with both primary lymphedema (n ¼ 669) and secondary lymphedema (n ¼ 657) were included. Upper and lower limbs were examined in 296 and 602 patients, respectively. Twenty-two studies used a gadolinium-based contrast agent that was injected intracutaneously or subcutaneously in the interdigital web spaces. Contrast-enhanced T1-weighted combined with T2-weighted protocols were most frequently used. T1- weighted images showed lymphatics in 63.3% to 100%, even in vessels with a diameter of $0.5 mm. Dermal backflow and a honeycomb pattern were clearly recognized.

Conclusions: MRL identifies superficial lymphatic vessels with a diameter of $0.5 mm with high sensitivity and specificity and accurately shows abnormal lymphatics and lymphatic drainage patterns. Therefore, MRL could be of clinical value in both early and advanced stages of peripheral lymphedema. Minimum requirements of an MRL protocol should consist of a gadolinium-based contrast-enhanced T1-weighted gradient-recalled echo sequence combined with T2-weighted magnetic resonance imaging, with acquisition at least 30 minutes after injection of contrast material.

Body image distress in head and neck cancer patients: what are we looking at? - click for abstract

Body image distress in head and neck cancer patients: what are we looking at?

H. C. Melissant 1,2,3 & F. Jansen1,2,3 & S. E. Eerenstein1 & P. Cuijpers3 & E. Laan4 & B. I. Lissenberg-Witte5 & A. S. Schuit3 & K. A. Sherman6 & C. R. Leemans1 & I. M. Verdonck-de Leeuw1,2,3. Supportive Care in Cancer. 2020

Purpose The aim of the present study is to investigate the prevalence of body image distress among head and neck cancer (HNC) patients after treatment and to examine its association with sociodemographic and clinical factors, health-related quality of life (HRQOL), HNC symptoms, sexuality, self-compassion, and psychological distress. Second, we aim to explore daily life experiences of HNC patients regarding body image.

Methods A cross-sectional survey among HNC patients investigated the prevalence of body image distress based on the Body Image Scale. Multivariable logistic regression analysis was applied to study associations with sociodemographic and clinical factors, HRQOL (EORTC QLQ-C30), HNC symptoms (QLQ-HN43), sexuality (FSFI-6; IIEF-5), self-compassion (SCS-SF), and psychological distress (HADS). Qualitative data from a body image writing intervention was used to explore experiences in daily life related to body image.

Results Body image distress was prevalent in 13–20% (depending on cut-off scores) of 233 HNC patients. Symptoms of depression (p < 0.001), younger age (p < 0.001), problems with social contact (p = 0.001), problems with wound healing (p = 0.013), and larger extent of surgery (p = 0.014) were associated with having body image distress. This model explained 67% of variance. Writing interventions of 40 HNC patients showed that negative body image experiences were related to appearance and function, with social functioning problems described most often. Conclusion Prevalence of body image distress in HNC patients, using different cut-off scores, is 13–20%. Younger patients, patients after extensive surgery, and patients who had wound healing problems are most at risk. There is a significant association between body image distress and depressive symptoms and social functioning.

Clinician Assessment of Upper Limb Lymphedema: An Observational Study- click for abstract

Clinician Assessment of Upper Limb Lymphedema: An Observational Study.

Robyn Sierla PhD,1,2 Elizabeth S. Dylke, PhD,1 Tim Shaw, PhD,1, Simon Poon, PhD,3 and Sharon L. Kilbreath, PhD. Lymphatic Research Biology. 2020

Background: Clinical management of lymphedema requires assessment, initially for detection, and then for determining treatment response and informing the treatment plan. It is unknown how the components of a lymphedema assessment are used in a clinical environment.

Methods and Results: Experienced lymphedema therapists were observed assessing patients presenting with new or existing upper body lymphedema. Occupational and physiotherapists specializing in lymphedema management (n = 14) from public and private, rural and urban settings in Australia were visited at their work sites and observed with a minimum of two patients. In total, 37 upper limb assessments were observed. Reasons for attendance included: initial assessment with new swelling (n = 4); screening/detection for possible lymphedema (n = 3); bandaging as part of an intensive treatment program (n = 2); and review (n = 28). Clinicians were observed, in order of frequency, using (1) patient-reported outcomes, (2) palpation, (3) visual assessment, (4) assessment of limb size using circumference measurements, and (5) assessment of extracellular fluid using bioimpedance spectroscopy. Although clinicians selected similar assessments, differences were observed in the measurement protocols and informed reported. Objective assessment was commonly absent when the time available for an appointment was 30 minutes.

Conclusions: While clinicians spent a significant portion of an appointment time assessing the limb, a standardized approach to the assessment of lymphedema was not observed. In the absence of a standardized assessment set, therapists have developed bespoke assessment routines.

The Quality of Life and Psychosocial Implications of Cancer‐Related Lower‐Extremity Lymphedema: A Systematic Review of the Literature- click for abstract

The Quality of Life and Psychosocial Implications of Cancer‐Related Lower‐Extremity Lymphedema: A Systematic Review of the Literature

Catharine Bowman, Katherine‐Ann Piedalue, Mohamad Baydoun and Linda E. Carlson. J. Clin. Med. 2020, 9, 3200

Lower‐extremity lymphedema (LEL) is a progressive, lifelong complication of cancer that places a substantial burden upon cancer survivors’ quality of life (QOL) and psychosocial well‐ being. Despite its prevalence, cancer‐related LEL is inconsistently diagnosed, treated, and poorly recognized by health care professionals. The purpose of this systematic review was to summarize and appraise the quantitative literature evaluating the impact of cancer‐related LEL on patients’ psychosocial well‐being and QOL. Three databases (PubMed, PROQuest, and Scopus) were searched for observational research articles published before May 1st, 2020. Twenty‐one articles were eligible (cross‐sectional (n = 16), prospective cohort designs (n = 3), and retrospective cohort designs (n = 2)). The majority of studies reported a negative relationship between cancer‐related LEL and global QOL and/or one or more psychosocial domains including (1) physical and functional; (2) psycho‐emotional; (3) social, relational and financial. A greater number of LEL symptoms and higher LEL severity were associated with poorer QOL. Although the evidence to date suggests a negative relationship between cancer‐related LEL and patients’ QOL and psychosocial well‐being, there is a substantial need for longitudinal analyses to examine the directionality and temporality of this effect in order to inform cancer survivorship care modelling and improve patient outcomes after cancer.

Diagnostic approach to lower limb edema

Antonios P Gasparis1 , Pamela S Kim2 , Steven M Dean3, Neil M Khilnani4 and Nicos Labropoulos. Phlebology 2020, Vol. 35(9) 650–655

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Management Strategies

Diagnosis and management of lipoedema – a review paper - click for abstract

Diagnosis and management of lipoedema – a review paper

Szypłowska Małgorzata, Gorecka Adrianna, Kuś Adrian, Zaremba Bartłomiej, Obel Michał. Journal of Education, Health and Sport. 2020;10(9):494-499

Lipoedema is a chronic progressive disorder of adipose tissue leading to an enlargement of lower extremities. It is considered to be rare; however, the prevalence of the disease is underestimated because it is commonly  misdiagnosed as obesity or lymphedema and the general awareness is poor. The etiology of the disorder is considered to be multifarious, including genetic inheritance, hormonal imbalance and microcirculation alterations. Diagnosis is mainly based on medical history and physical examination. Management of lipoedema is focused on reducing the symptoms, improving the quality of life and preventing further progression of the disease. The aim of this paper is to raise the awareness of the disease and provide appropriate clinical guidance for the assessment of lipoedema. We searched through the PubMed/MEDLINE database and took into consideration all of the results available as of 6 September, 2020 and outlined the current evidence regarding lipoedema epidemiology, etiology, clinical presentation, differential diagnosis, and management. Better understanding of lipoedema is crucial for establishing an early diagnosis and a proper treatment, which in turn will reduce the psychological and physical implications associated with the disease.

Breast Cancer–Related Lymphedema: Personalized Plans of Care to Guide Survivorship. - click for abstract

Breast Cancer–Related Lymphedema: Personalized Plans of Care to Guide Survivorship.

Allison B. Anbari1 & Pamela Ostby1 & Pamela K. Ginex2. Current Breast Cancer Reports. October 2020.

Purpose To present and discuss care domains (oncologic, cardiometabolic, aging, behavioral, environmental) for clinicians when approaching care for a breast cancer survivor at risk for developing breast cancer–related lymphedema (BCRL), as well as survivors who have been diagnosed with BCRL. Assessment using each domain aids in decision-making, yet also identifies barriers to pursuing personalized care for survivors with BCRL.

Recent Findings BCRL occurs from damage to the lymphatics during breast cancer treatment and occurs in approximately 20 to 40% of survivors. Prospective surveillance and early treatment for BCRL are supported in the literature; however, these approaches are frequently not used within evidence-based recommendations.

Summary The five domains can be used to develop a personalized plan of BCRL care. Barriers to pursuing personalized care for survivors with BCRL are identified. Future work in developing evidence-based recommendations is needed to guide clinicians and survivors during prospective surveillance, successful risk reduction, early diagnosis, and treatment of BCRL.

Association between external and internal lymphedema and chronic dysphagia following head and neck cancer treatment - click for abstract

Association between external and internal lymphedema and chronic dysphagia following head and neck cancer treatment

Jeans C, Ward EC, Brown B, et al. Head & Neck. 2020;1–13

Background: To examine the relationship between chronic external and internal head and neck lymphedema (HNL) and swallowing function in patients following head and neck cancer (HNC) treatment.
Methods: Seventy-nine participants, 1-3 years post treatment were assessed for external HNL using the MD Anderson Cancer Centre Lymphedema Rating Scale, and internal HNL using Patterson’s Radiotherapy Edema Rating Scale. Swallowing was assessed via instrumental, clinical and patient-reported outcome measures.

Results: HNL presented as internal only (68%), combined external/internal (29%), and external only (1%). Laryngeal penetration/aspiration was confirmed in 20%. Stepwise multivariable regression models, that accounted for primary site, revealed that a higher severity of external HNL and internal HNL was
associated with more severe penetration/aspiration (P < .004 and P = .006, respectively), diet modification (P < .001 both), and poorer patient-reported outcomes (P = .037 and P = .014, respectively). [/av_toggle] [/av_toggle_container] [av_hr class='invisible' height='50' shadow='no-shadow' position='center' custom_border='av-border-thin' custom_width='50px' custom_border_color='' custom_margin_top='30px' custom_margin_bottom='30px' icon_select='yes' custom_icon_color='' icon='ue808' font='entypo-fontello'] [av_toggle_container initial='0' mode='accordion' sort='' styling='' colors='' font_color='' background_color='' border_color=''] [av_toggle title='Compression therapy for leg oedema in patients with heart failure - click for abstract' tags=''] Compression therapy for leg oedema in patients with heart failure

Tomasz Urbanek, Maciej Juśko* and Wacław B. Kuczmik. ESC Heart Failure 2020; 7: 2012–2020.

The presence of chronic heart failure (CHF) results in a significant risk of leg oedema. Medical compression (MC) treatment is one of the basic methods of leg oedema elimination in patients with chronic venous disease and lymphedema, but it is not routinely considered in subjects with CHF-related swelling. In the study, an overview of the current knowledge related to the benefits and risk of using MC in the supportive treatment of leg oedema in CHF patients is presented. The available studies dedicated the comprehensive management of leg swelling using MC in CHF patients published in the English language literature till December 2019 were evaluated in term of the treatment efficacy and safety. In studies performed on CHF populations, manual lymphatic drainage, MC stocking, multilayer bandaged, as well as intermittent pneumatic compression or electric calf stimulations were used. The current evidence is based on non-randomized studies, small study cohorts, as well as very heterogenous populations. The use of the intermittent pneumatic compression in CHF patients significantly increases the right auricular pressure and mean pulmonary artery pressures as well as decreases systemic vascular resistance in most patients without the clinical worsening. The transient and rapid increase in the human atrial natriuretic peptide, after an application of the MC stocking in New York Heart Association (NYHA) class II patients was observed without clinical exacerbation. An application of the multilayer bandages in NYHA classes III and IV patients lead a significant increase in the right arterial pressure and lead to transient deterioration of the right and the left ventricular functions. In the manual lymphatic drainage study, aside from expected leg circumference reduction, no clinical worsening was observed. In a pilot study performed in a small cohort of CHF patients, electrical calf stimulation use resulted in a reduction in the lean mass of the legs without cardiac function worsening. The use of local leg compression can be considered stable CHF patients without decompensated heart function for both CHF-related oedema treatment and for treatment of the concomitant diseases leading to leg swelling occurrence. The use of MC in more severe classes of CHF (NYHA III and IV) should be the subject of future clinical studies to select the safest and most efficient compression method as well as to select the patients who benefit most from this kind of treatment.