Hot of the Press November 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
A Systematic Review of Peripheral Neuropathies in Breast Cancer-Related Lymphedema - click for abstract
A Systematic Review of Peripheral Neuropathies in Breast Cancer-Related Lymphedema
Antonio J Forte, Maria T Huayllani, Daniel Boczar, Oscar J Manrique, Xiaona Lu, Sarah A McLaughlin, Theodore A Kung. Hand (N Y). 2020 Oct 19:1558944720963944.
Controversy exists regarding the influence of breast cancer-related lymphedema (BCRL) in the development of peripheral neuropathies. Our aim was to evaluate the association of secondary lymphedema with peripheral neuropathies in patients with breast cancer. We performed a systematic review by querying PubMed, EMBASE, Ovid Medline and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, and Cochrane Central Register of Controlled Trials databases. The keywords “lymphedema” AND (“neuropathy” OR “carpal tunnel syndrome” OR “cubital tunnel syndrome” OR “neuropathic pain”) and synonyms in titles and abstracts were used to perform the search. Seventeen articles met the inclusion criteria. Discrepancies were found in studies that analyzed whether a cause-effect association exists between carpal tunnel syndrome (CTS) and secondary lymphedema. No evidence indicated that lymphedema predisposes to developing peripheral neuropathies such as CTS or brachial plexopathy. No studies found an association between patients with breast cancer at risk of or with lymphedema and the development or worsening of CTS. Carpal tunnel release can be safely performed in patients with BCRL. Neuropathic pain worsens with lymphedema, and treatment seems to improve the pain. Our study did not find enough evidence to conclude that BCRL is associated with the development of peripheral neuropathies. Carpal tunnel release is a safe procedure that can be performed in patients with BCRL and does not influence the development or worsening of lymphedema. Neuropathic pain seems to worsen after development of lymphedema, and treatment has been found to improve neuropathic pain.
Change of the Lymphatic Diameter in Different Body Positions - click for abstract
Change of the Lymphatic Diameter in Different Body Positions
Hisako Hara, Makoto Mihara. Lymphat Res Biol. 2020 Oct 15.
Background: Until now, lymphatic ultrasound was performed with the patients in the prone position. The aim of this study was to evaluate the change in the lymphatic diameter in different body positions. Methods: We performed a retrospective study. We performed indocyanine green (ICG) lymphography and lymphatic ultrasound as a pre-operative examination for lymphaticovenous anastomosis (LVA). ICG was injected at three lymphosomes per limb (the saphenous lymphatics, lateral thigh lymphatics, and lateral calf lymphatics). For the lymphatic ultrasound, a commonly used ultrasound device with an 18 MHz linear probe was employed. We measured the lymphatic diameter in the designed LVA sites in prone, sitting, and upright position. Results: We investigated 61 limbs of 31 female patients with lower limb lymphedema. The mean age was 62.0 (range: 42-86) years. We measured the lymphatic diameter at 78 sites in the thigh and 76 sites in the lower leg. In the thigh, the mean lymphatic diameters in the supine and upright positions were 0.43 ± 0.02 mm and 0.40 ± 0.02 mm, respectively, with no significant difference (p = 0.10). In the lower leg, the mean lymphatic diameters in the supine, sitting, and upright positions were 0.68 ± 0.04 mm, 0.63 ± 0.04 mm, and 0.63 ± 0.04, respectively. A significant decrease was noted between the supine and sitting positions (p = 0.02). Conclusions: The lymphatic diameter in the lymphedematous lower limbs tended to decrease when the patients changed their body position from supine to the sitting or upright positions.
Lower Extremity Lymphatic Function in Nonambulatory Patients with Neuromuscular Disease- click for abstract
Lower Extremity Lymphatic Function in Nonambulatory Patients with Neuromuscular Disease
Arin K Greene, Christopher L Sudduth. Lymphat Res Biol. 2020 Nov 6.
Background: Lymphedema results from inadequate lymphatic function causing swelling in subcutaneous tissues. Lymph is transported proximally through valved lymphatic channels and muscle contraction. The purpose of this study was to determine lymphatic function in nonambulatory patients with lower extremity neuromuscular disease.
Methods and Results: Our Lymphedema Program database of 700 patients was reviewed for nonambulatory patients with lower extremity neuromuscular disease. Patient age, gender, disease, body mass index (BMI), and lymphoscintigram result were recorded. Eight patients were included in the study: myelomeningocele (n = 6), spinal muscle atrophy type 2 (n = 1), Charcot Marie Tooth (n = 1). Patient ages were between 15 and 36 years; five were female. BMI range for patients without swelling or a normal lymphoscintigram (n = 4) was 22-27. Four subjects with lymphatic dysfunction by lymphoscintigram all were obese (BMI 36-74; p = 0.03).
Conclusions: Nonambulatory patients with lower extremity neuromuscular dysfunction and swelling can exhibit normal lymphatic function. Obesity is associated with abnormal lymphoscintigram result and lymphedema in this patient population. Individuals should be advised to maintain a normal BMI.
Sarcopenia in aging, obesity, and cancer
Jennifer A Ligibel, Kathryn H. Schmitz, Nathan A Berger. Transl Cancer Res. 2020 Sep;9(9):5760-5771
Prevalence and Risk Factors
Associated risk factors of lower limb lymphedema after treatment of cervical and endometrial cancer - click for abstract
Associated risk factors of lower limb lymphedema after treatment of cervical and endometrial cancer
Laura Florentina Rebegea, Gabriela Stoleriu, Nicuta Manolache, Cristina Serban, Mihaela Craescu, Mary-Nicoleta Lupu, Doina Carina Voinescu, Dorel Firescu, Oana Roxana Ciobotaru. Exp Ther Med. 2020 Dec;20(6):181.
The scope of the study was to identify the associated risk factors of lower limb lymphedema development in cervical and endometrial cancer patients. We retrospectively analysed 326 patients: 186 cases (57.06%) with cervical cancer and 140 cases (42.94%) with endometrial cancer were treated in Surgery, Radiotherapy, Oncology and Gynaecology Clinics of ‘St. Apostle Andrew’ Emergency Clinical Hospital Galati over 9 years. Adjuvant radiotherapy was performed in 83.57% of endometrial cancer cases. Adjuvant chemotherapy was performed in 45.16% of cervical cancer cases. Over 10 lymph nodes were removed in 74.73% of cervical cancer patients. Incidence of lymphedema was 15.05% in cervical cancer patients and 10% in endometrial cancer patients, P=0.06. Analysed risk factors for lower limb lymphedema occurrence were: Age, disease stage, radiotherapy, number of invaded lymph nodes (for cervical cancer patients), number of removed lymph nodes (for cervical cancer patients) and obesity. Multivariate analysis for associated risk factors of lower limb lymphedema development in cervical cancer showed that number of removed lymph nodes, OR=2.109 (0.907-4.903), P<0.0001, number of lymph nodes with metastasis, OR=1.903 (0.253-4.332), P=0.004 and obesity, OR=1.713 (0.226-2.967), P=0.006 were found as statistically significant risk factors for lower limb lymphedema onset. For endometrial cancer patients, obesity, OR=1.518 (0.721-2.75), P=0.0003, was the only associated risk factor with statistical significance for the lower limb lymphedema development. Lower limb lymphedema represents one of the adverse reactions of multimodal treatment in gynaecological cancers which affects patient's quality of life. Lower limb lymphedema occurrence is related with number of risk factors, the most important being removed lymph nodes, obesity and radiotherapy. [/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='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' tags=''] 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
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.
The Role of Patient Awareness and Knowledge in Developing Secondary Lymphedema after Breast and Gynecologic Cancer Surgery - click for abstract
The Role of Patient Awareness and Knowledge in Developing Secondary Lymphedema after Breast and Gynecologic Cancer Surgery
Secil Pervane Vural, Fikriye Figen Ayhan, Atilla Soran. Lymphat Res Biol. 2020 Oct 7.
Background: This study aimed to compare the effects of awareness and knowledge on demographic and clinical factors in patients with breast cancer-related lymphedema (BCRL) and gynecologic cancer-related lymphedema (GCRL) in the oncologic rehabilitation setting.
Methods and Results: A total of 506 female patients with upper or lower extremity lymphedema, were evaluated for lymphedema education in their postoperative period. Only 74 survivors (25%) with BCRL and 34 survivors (16.83%) with GCRL reported that they had received information about lymphedema by physicians/primary health care providers. In breast cancer survivors, the time of diagnostic delay for lymphedema was shorter in the informed group (p < 0.001), and there was a higher rate of cellulite attacks in uninformed patients (p = 0.021). Duration between surgery and lymphedema was longer and duration of diagnostic delay for lymphedema was shorter in the informed group than uninformed group in gynecologic cancer survivors (p = 0.019, p < 0.001). There was a higher rate of cellulite history in the uninformed patients than informed patients in gynecologic cancer survivors (p < 0.001). In gynecologic cancer survivors who were educated about lymphedema were at an earlier stage than noneducated patients (p = 0.024).
Conclusion: The rate of awareness about lymphedema among patients with a history of surgery for gynecologic malignancies is lower compared with those for breast cancer. In female cancer survivors, awareness and knowledge about lymphedema may lead to a later onset of lymphedema, lower lymphedema grades, and fewer infection.
Assessment
Feasibility of implementing a text-based symptom-monitoring program of endometrial, ovarian, and breast cancer patients during treatment
Michelle J Naughton, Ritu Salani, Juan Peng, Maryam Lustberg, Cecilia DeGraffinreid, Jennifer Moon, Hibaq Loyan, Chloe M Beverly Hery, Electra D. Paskett. Qual Life Res. 2020 Oct 14.
Refinement and Validation of the Head and Neck Lymphedema and Fibrosis Symptom Inventory- click for abstract
Refinement and Validation of the Head and Neck Lymphedema and Fibrosis Symptom Inventory
Jie Deng, Mary S Dietrich, Kenneth J Niermann, Robert J Sinard, Anthony J Cmelak, Sheila H Ridner, Jill Gilbert, Barbara A Murphy. Int J Radiat Oncol Biol Phys. 2020 Oct 14:S0360-3016(20)34387-X.
PURPOSE: Lymphedema and fibrosis (LEF) are common yet overlooked late effects of head and neck cancer (HNC) and its therapy. Lack of reliable and valid measures of head and neck LEF is a critical barrier to the timely identification and management of head and neck LEF. To fill in this gap, we developed, and pilot tested a 64-item patient-reported outcome measure (L-survey, abbreviated for purpose of blinding). The article aimed to report the process of further validation and refinement of the tool.
METHODS AND MATERIALS: A prospective, longitudinal study was conducted and 120 patients with oral cavity and oropharyngeal cancer were recruited. Participants completed the L-survey at pre-treatment, end of treatment, and every three months up to 12 months after treatment. SAS PROC VARCLUS was used to generate preliminary clusters of item responses. Internal consistency of the item responses within each cluster was assessed using Cronbach’s Alpha.
RESULTS: A total of 117 patients completed the study. The participants reported that the L-survey was easy to understand, and the survey captured their symptoms and medical conditions. However, greater than 50% of participants indicated that the survey was burdensome due to length. Thus, we proceeded with item reduction and the shortened tool (33-item) was named H-symptom inventory. The subsequent exploration of symptom clusters identified seven symptom domain clusters (e.g., soft tissue and neurologic toxicity), all of which demonstrated good internal consistency.
CONCLUSIONS: The H-symptom inventory has been carefully developed and refined to allow clinicians and researchers to capture LEF associated symptom burden and function impairments. Additional rigorous psychometric testing of the tool is ongoing to further validate the strength and internal validity of this tool.
Current Concepts in the Diagnosis and Management of Lymphedema- click for abstract
Current Concepts in the Diagnosis and Management of Lymphedema
Alisha Oropallo, Miriam Donis-Garcia, Soyouen Ahn, Amit Rao. Adv Skin Wound Care. 2020 Nov;33(11):570-580.
GENERAL PURPOSE: To present a comprehensive review of lymphedema, including its pathophysiology, assessment, diagnosis, and treatment.
TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.
LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant will:1. Summarize the etiology, pathophysiology, and clinical manifestations of lymphedema.2. Describe the diagnostic and treatment approaches for patients who have lymphedema.: Lymphedema is a condition characterized by localized protein-rich swelling caused by damaged or malfunctioning lymphatics. Patients with lymphedema have an increased risk of infection because of the lymphostatic nature of the disease. Chronic ulceration of the skin can make individuals vulnerable to infection leading to serious, sometimes fatal, complications. Proper diagnosis and treatment modalities can aid in the prevention of these complications and ensure better outcomes for the patient
The effect of limb position on the reliability of leg circumference measurements in patients diagnosed with lower limb lymphoedema - click for abstract
The effect of limb position on the reliability of leg circumference measurements in patients diagnosed with lower limb lymphoedema
R Scheer, E Crofton, N Andrews. Support Care Cancer. 2020 Oct 21
Objective: To establish the intrarater reliability of lower limb circumference measures in a sample of individuals who are diagnosed with lower limb lymphoedema and to evaluate if change in limb position has an effect on the reliability of circumferential measures.
Method: A sample of forty-one adults diagnosed with a lower limb lymphoedema were recruited. Participants had their affected leg measured three times by a qualified therapist during a standard outpatient appointment: twice in a lying position and once in sitting with knee flexed at 90°. To examine the intrarater reliability, interclass correlation coefficients (ICC) with 95% confident intervals were calculated.
Results: Excellent intrarater reliability was established at each measurement point and for the sum of circumferential measures when the limb remeasured in the same position by the same therapist. Changing the position of the limb resulted in lower intrarater reliability values at 10 and 30 cm from the base of the foot.
Conclusions: The current study provides evidence for the intrarater reliability of lower limb circumference measures and highlights the need for consistency when remeasuring and monitoring the limb of those diagnosed with lower limb lymphoedema.
Implications for cancer survivors: Lymphoedema is a significant problem for breast cancer survivors but also provides lifetime risk to all survivors of lymph node surgery for solid tumours. The monitoring and surveillance of leg circumference measures of people diagnosed with lower limb lymphoedema has been a valuable instrument when reviewing progress of this chronic condition.
Standardization of lower extremity quantitative lymphedema measurements and associated patient-reported outcomes in gynecologic cancers - click for abstract
Standardization of lower extremity quantitative lymphedema measurements and associated patient-reported outcomes in gynecologic cancers
Sandra Russo, Joan L Walker, Jay W Carlson, Jeanne Carter, Leigh C Ward, Allan Covens, Edward J Tanner, Jane M. Armer, Sheila Ridner, Sandi Hayes, Alphonse G Taghian, Cheryl Brunelle, Micael Lopez-Acevedo, Brittany A Davidson, Mark V Schaverien, Sharad A Ghamande, Michael J. Bernas, Andrea L. Cheville, Kathleen J Yost, Kathryn H. Schmitz, Barbara Coyle, Jeannette Zucker, Danielle Enserro, Stephanie Pugh, Electra D. Paskett, Leslie Ford, Worta McCaskill-Stevens. Gynecol Oncol. 2020 Nov 3:S0090-8258(20)34048-8.
Practice changing standardization of lower extremity lymphedema quantitative measurements with integrated patient reported outcomes will likely refine and redefine the optimal risk-reduction strategies to diminish the devastating limb-related dysfunction and morbidity associated with treatment of gynecologic cancers. The National Cancer Institute (NCI), Division of Cancer Prevention brought together a diverse group of cancer treatment, therapy and patient reported outcomes experts to discuss the current state-of-the-science in lymphedema evaluation with the potential goal of incorporating new strategies for optimal evaluation of lymphedema in future developing gynecologic clinical trials.
A virtual environment to evaluate the arm volume for lymphedema affected patients - click for abstract
A virtual environment to evaluate the arm volume for lymphedema affected patients
Andrea Vitali, Giovanni Togni, Daniele Regazzoni, Caterina Rizzi, Guido Molinero. Comput Methods Programs Biomed. 2020 Oct 24;198:105795.
Background and objective: The paper presents a novel procedure based on 3D scanning and 3D modelling to automatically assess linear and volumetric measurements of an arm and to be further applied to patients affected by post breast cancer lymphedema. The aim is the creation of a virtual platform easily usable by medical personnel to get more objective evaluations during the lymphedema treatment.
Methods: The procedure is based on the 3D scanning of the arm using the Occipital Structure Sensor and an ad-hoc developed application, named Lym 3DLab. Lym 3DLab emulates the traditional measurement methods, which consist in taking manual circumference measurements or using the water displacement method. These measurements are also used to design the compression stockings, the typical orthopaedic device used for lymphedema treatment. A validation test has been performed to compare the measurements computed by Lym 3DLab with both water displacement and manual circumference measurements. Eight volunteers have been involved who are not affected by lymphedema. Furthermore, a specific usability test has been performed to evaluate the 3D scanning procedure by involving four physiotherapists.
Results: The comparison between the volumes has highlighted how all the 3D acquired models have their volumes inside a range of acceptability. This range has been defined by considering the sensitivity error of the tape measure used to measure the water displacement. The comparison between the perimeters of cross sections computed with Lym 3DLab and the circumference measurements has shown results that are very accurate with an average difference of 2 mm. The measure errors have been considered negligible by the medical personnel who have evaluated the proposed procedure more accurate than the traditional ones. The test with physiotherapists has shown a high level of usability of the whole virtual environment, but the 3D scanning procedure requires an appropriate training of the personnel to make the 3D acquisition as fast and efficient as possible.
Conclusions: The achieved results and the physiotherapists’ feedback allow planning a future test with patients affected by lymphedema in collaboration with the hospital. A further test has been planned to use the computed measurements to design orthopaedic compression stockings.
GOG 244 - The Lymphedema and Gynecologic cancer (LeG) study: The impact of lower-extremity lymphedema on quality of life, psychological adjustment, physical disability, and function - click for abstract
GOG 244 – The Lymphedema and Gynecologic cancer (LeG) study: The impact of lower-extremity lymphedema on quality of life, psychological adjustment, physical disability, and function
Jeanne Carter, Helen Q Huang, Jane M. Armer, Jay W Carlson, Suzy Lockwood, Susan Nolte, James Kauderer, Alan Hutson, Joan L Walker, Aimee C Fleury, Albert Bonebrake, John T Soper, Cara Mathews, Oliver Zivanovic, William Edward Richards, Annie Tan, David S Alberts, Richard R Barakat, Lari B Wenzel. Gynecol Oncol. 2020 Oct 24:S0090-8258(20)34045-2.
OBJECTIVE: To assess quality of life (QOL) in patients who developed lower-extremity lymphedema (LLE) after radical gynecologic cancer surgery on prospective clinical trial GOG 244.
METHODS: The prospective, national, cooperative group trial GOG-0244 determined the incidence of LLE and risk factors for LLE development, as well as associated impacts on QOL, in newly diagnosed patients undergoing surgery for endometrial, cervical, or vulvar cancer from 6/4/2012-11/17/2014. Patient-reported outcome (PRO) measures of QOL (by the Functional Assessment of Cancer Therapy [FACT]), body image, sexual and vaginal function, limb function, and cancer distress were recorded at baseline (within 14 days before surgery), and at 6, 12, 18, and 24 months after surgery. Assessments of LLE symptoms and disability were completed at the time of lower limb volume measurement. A linear mixed model was applied to examine the association of PROs/QOL with a Gynecologic Cancer Lymphedema Questionnaire (GCLQ) total score incremental change ≥4 (indicative of increased LLE symptoms) from baseline, a formal diagnosis of LLE (per the GCLQ), and limb volume change (LVC) ≥10%.
RESULTS: In 768 evaluable patients, those with a GCLQ score change ≥4 from baseline had significantly worse QOL (p < 0.001), body image (p < 0.001), sexual and vaginal function (p < 0.001), limb function (p < 0.001), and cancer distress (p < 0.001). There were no significant differences in sexual activity rates between those with and without LLE symptoms. CONCLUSIONS: LLE is significantly detrimental to QOL, daily function, and body image. Clinical intervention trials to prevent and manage this chronic condition after gynecologic cancer surgery are needed.
Management Strategies
A randomized study to prevent lymphedema in women treated for breast cancer: CALGB 70305 (Alliance)- click for abstract
A randomized study to prevent lymphedema in women treated for breast cancer: CALGB 70305 (Alliance)
Electra D. Paskett, Jennifer Le-Rademacher, Jill M Oliveri, Heshan Liu, Drew K Seisler, Jeffrey A Sloan, Jane M. Armer, Michelle J Naughton, Karen Hock, Michael Schwartz, Gary Unzeitig, Marianne Melnik, Lisa D Yee, Gini F Fleming, John R Taylor, Charles Loprinzi. Cancer. 2020 Oct 20.
BACKGROUND: Lymphedema affects many women who are treated for breast cancer. We examined the effectiveness of an education-only (EO) versus education plus sleeve compression/exercise intervention (lymphedema education and prevention [LEAP]) on lymphedema incidence and range of motion (ROM) in a group-randomized trial across 38 cooperative group sites.
METHODS: The treating institution was randomly assigned to either EO or LEAP by a study statistician. All patients at a treating institution participated in the same intervention (EO or LEAP) to minimize contamination bias. Participants completed surveys, arm volume measurements, and self-reported ROM assessments before surgery and at 12 and 18 months after surgery. Lymphedema was defined as a ≥10% difference in limb volume at any time post-surgery up to 18 months after surgery or diagnosis by a health provider. Cochran-Mantel-Haenszel tests were used to compare lymphedema-free rates between groups, stratified by lymph node surgery type. Self-reported ROM differences were compared between groups.
RESULTS: A total of 554 participants (56% LEAP) were included in the analyses. At 18 months, lymphedema-free rates were 58% (EO) versus 55% (LEAP) (P = .37). ROM for both arms was greater in LEAP versus EO at 12 months; by 18 months, most women reported full ROM, regardless of group. In LEAP, only one-third wore a sleeve ≥75% of the time; 50% performed lymphedema exercises at least weekly.
CONCLUSION: Lymphedema incidence did not differ by intervention group at 18 months. Poor adherence in the LEAP group may have contributed. However, physical therapy may speed recovery of ROM. Further research is needed to effectively reduce the incidence and severity of lymphedema in patients who have breast cancer.
Health-related quality of life outcomes for the LEAP study-CALGB 70305 (Alliance): A lymphedema prevention intervention trial for newly diagnosed breast cancer patients. - click for abstract
Health-related quality of life outcomes for the LEAP study-CALGB 70305 (Alliance): A lymphedema prevention intervention trial for newly diagnosed breast cancer patients
Michelle J Naughton, Heshan Liu, Drew K Seisler, Jennifer Le-Rademacher, Jane M. Armer, Jill M Oliveri, Jeffrey A Sloan, Karen Hock, Michael Schwartz, Gary Unzeitig, Marianne Melnik, Lisa D Yee, Gini F Fleming, John R Taylor, Charles Loprinzi, Electra D. Paskett. Cancer. 2020 Oct 20. doi: 10.1002/cncr.33184.
BACKGROUND: Lymphedema is an adverse effect of breast cancer treatment that causes swelling and pain in the arm and hand. We tested 2 lymphedema prevention interventions and their impact on health-related quality of life (HRQOL) in a group-randomized trial at 38 cooperative group sites within the United States.
METHODS: Patients were recruited before breast surgery. Sites were randomly assigned to education-only (EO) lymphedema prevention or education plus exercise and physical therapy (LEAP). Lymphedema was defined as a ≥10% difference in arm volume at any time from baseline to 18 months postsurgery. HRQOL was assessed using the Functional Assessment of Cancer Therapy-Breast plus 4 lymphedema items (FACT-B+4). Longitudinal mixed model regression analysis, adjusting for key demographic and clinical variables, examined participants’ HRQOL by intervention group and lymphedema status.
RESULTS: A total of 547 patients (56% LEAP) were enrolled and completed HRQOL assessments. The results revealed no differences between the interventions in preventing lymphedema (P = .37) or HRQOL (FACT-B+4 total score; P = .8777). At 18 months, the presence of lymphedema was associated with HRQOL at borderline significance (P = .0825). However, African American patients reported greater lymphedema symptoms (P = .0002) and better emotional functioning (P = .0335) than patients of other races or ethnicities. Lower HRQOL during the intervention was associated with younger age (P ≤ .0001), Eastern Cooperative Oncology Group performance status >0 (P = .0002), ≥1 positive lymph nodes (P = .0009), having no education beyond high school (P < .0001), having undergone chemotherapy (P = .0242), and having had only axillary node dissection or sentinel node biopsy versus both (P = .0007). CONCLUSION: The tested interventions did not differ in preventing lymphedema or in HRQOL outcomes. African American women reported greater HRQOL impacts due to lymphedema symptoms than women of other races or ethnicities
Manual Lymphatic Drainage May Not Have an Additional Effect on the Intensive Phase of Breast Cancer-Related Lymphedema: A Randomized Controlled Trial - click for abstract
Manual Lymphatic Drainage May Not Have an Additional Effect on the Intensive Phase of Breast Cancer-Related Lymphedema: A Randomized Controlled Trial
Ekin Ilke Sen, Sina Arman, Mert Zure, Hadi Yavuz, Dilsad Sindel, Aydan Oral. Lymphat Res Biol. 2020 Oct 15.
Background: Breast cancer-related lymphedema (BCRL) is a potentially debilitating complication of breast cancer and its treatment. The aim of this study was to determine the efficacy of manual lymphatic drainage (MLD) added to multilayer compressive bandage treatment in addition to an exercise program, on arm volume, subjective symptoms, upper limb functions, and health-related quality of life (HRQoL) in patients with BCRL.
Methods: This prospective, randomized, single-blind interventional trial involved 54 patients with BCRL. Eligible patients were randomly allocated to a complex decongestive therapy (CDT) group (n = 27) and a standard therapy (ST) group (n = 27). Both groups participated in a 15-session program (every weekday for 3 weeks) that included compressive multilayer bandaging and exercise training. The patients who were allocated to the CDT group received MLD before bandaging in addition to the ST. Bilateral arm circumferences were measured using a measuring tape at six reference points. Subjective symptoms, such as discomfort, heaviness, and swelling severity were measured using a visual analog scale (VAS). Upper limb functions and HRQoL were assessed using the Quick Disabilities of the Arm, Shoulder and Hand (Quick-DASH) and Lymphedema Functioning, Disability, and Health Questionnaire (Lymph-ICF), respectively.
Results: The excess arm volume, percent change of excess arm volume, Quick-DASH scores, and Lymph-ICF subscale scores significantly decreased (p < 0.001) in both treatment groups. However, there was no significant difference between the two groups (p > 0.05) in terms of changes in these outcomes. The VAS discomfort (p = 0.015) and VAS heaviness (p = 0.014) scores decreased significantly in the CDT group compared to the ST group.
Conclusion: The study findings indicated that both treatment approaches were effective in patients with BRCL. However, no additional effect of MLD was found with regard to percent reduction in arm volume in the intensive treatment period of BRCL.
Assessment of Quality of Life Changes in Lower Extremity Lymphedema Patients Using an Advanced Pneumatic Compression Device at Home- click for abstract
Assessment of Quality of Life Changes in Lower Extremity Lymphedema Patients Using an Advanced Pneumatic Compression Device at Home
Thomas S Maldonado, Rae S Rokosh, Frank Padberg, Vittorio Rotella, Hyman Miller, Naiem Nassiri, Glenn Jacobowitz, Todd Berland, Mikel Sadek, Michael E Barfield. J Vasc Surg Venous Lymphat Disord. 2020 Oct 30:S2213-333X(20)30558-8.
Objective: Lymphedema is associated with significant morbidity and healthcare resource usage. Conventional therapy efficacy is limited with poor surgical salvage options. Preliminary studies demonstrated advanced pneumatic compression devices (APCD) improve clinical outcomes, however limited evidence regarding their role in healthcare cost mitigation or health-related quality of life (QOL) is available.
Methods: This post-market multi-center single-arm observational clinical trial conducted in the Veterans Affairs (VA) Healthcare System evaluated patients with a diagnosis of primary or secondary edema of unilateral or bilateral lower extremities (LE) prescribed the Flexitouch APCD (FLX, Tactile MedicalTM) between February 2016 and March 2019. Patients were assessed at baseline, 12, 24, and 52 weeks from enrollment by limb circumference, QOL assessments (Short Form-36 [SF-36] and Lymphedema Quality of Life [LYMQOL]), device compliance, cellulitic episodes and lymphedema-related health care use since the previous visit. Primary endpoints of interest were QOL at baseline compared to 12 weeks as well as unscheduled lymphedema-related clinic visits and hospital admissions at 52 weeks. Secondary endpoints included change in limb girth and QOL at 52 weeks compared to baseline.
Results: 178 patients with LE lymphedema were prospectively enrolled; this interim report represents the first 74 subjects to complete 52 weeks of APCD treatment. The cohort was predominately male (94.6%), elderly (mean 67 years), obese (median BMI 32), and most commonly enrolled for treatment of phlebolymphedema (71.6%) with largely bilateral LE involvement (91.9%). There was no significant difference in QOL at 12 weeks. However, at 52 weeks, LYMQOL was significantly improved from baseline (6.3 vs. 7.4, p<0.0001) and SF-36 demonstrated significant improvement from baseline in the Physical Component (38.6 vs. 40.8; p=0.035) with an effect towards overall improvement as well in the Mental Component (49.9 vs. 51.3; p=0.549). Limb circumference was significantly reduced at 12 weeks from baseline (28.5cm vs. 27.7cm; p=0.0005) in the most affected LE, and this reduction remained stable for the study duration. APCD treatment was associated with a significant reduction in cellulitic incidence (24.3% vs. 8.1%, p=0.005), lymphedema-related clinic visits (2.2 vs. 0.7; p=0.02), urgent care visits (1.2 vs. 0.3; p=0.004), and hospital admissions (0.5 vs. 0.1; p=0.047) per patient. Conclusions: The FLX APCD results in initial significant limb girth reduction as early as 12 weeks and a steady sustained improvement in health-related QOL up to one year. The latter is likely reflective of a decrease in cellulitis episodes and fewer associated lymphedema-related clinic, urgent care visits and hospital admissions.
The Effects of Complex Decongestive Physiotherapy Applications on Lower Extremity Circumference and Volume in Patients with Lipedema- click for abstract
The Effects of Complex Decongestive Physiotherapy Applications on Lower Extremity Circumference and Volume in Patients with Lipedema
Melek Volkan-Yazıcı, Gokhan Yazici, Murat Esmer. Lymphat Res Biol. 2020 Oct 30.
Background: The aim of this study is to investigate the effect of complex decongestive physiotherapy (CDP) plus intermittent pneumatic compression (IPC) applications on lower extremity limb circumference and volume in patients with lipedema.
Methods and Results: In measurement of limb volume and circumference measurement, the Perometer 400 NT was used before and after treatment. The perometer measurements in this study were performed in the certain five reference points (cB, cC, cD, cE, and CF). All participants included in the study were included in a treatment protocol consisting of CDP and IPC. It was seen that statistically significant reduction was found in the circumference of 3 of the 5 points of measurements performed in the left limb, whereas statistically significant reduction was found in the circumference of 4 of the 5 points of measurements performed in the right limb. When the assessments of limb volume performed with the perometer were compared before and after CDP, it was seen that statistically significant reduction was found in the volume of both limbs.
Conclusion: This reduction indicates that CDP is effective in the treatment of lower extremity lipedema. Clinicaltrials.gov with an ID of NCT04492046.
Efficacy and efficiency of a new therapeutic approach based on activity-oriented proprioceptive antiedema therapy (TAPA) for edema reduction and improved occupational performance in the rehabilitation of breast cancer-related arm lymphedema in women: a controlled, randomized clinical trial
María Nieves Muñoz-Alcaraz, Luis Ángel Pérula-de-Torres, Jesús Serrano-Merino, Antonio José Jiménez-Vílchez, María Victoria Olmo-Carmona, María Teresa Muñoz-García, Cruz Bartolomé-Moreno, Bárbara Oliván-Blázquez, Rosa Magallón-Botaya, BMC Cancer. 2020 Nov 9;20(1):1074.
Physical activity level, exercise behavior, barriers, and preferences of patients with breast cancer-related lymphedema- click for abstract
Physical activity level, exercise behavior, barriers, and preferences of patients with breast cancer-related lymphedema
Vesile Yildiz Kabak, Ceren Gursen, Ayca Aytar, Turkan Akbayrak, Tulin Duger. Support Care Cancer. 2020 Nov 10
Purpose: To identify physical activity level, exercise behavior, barriers, and preferences in female patients with breast cancer-related lymphedema (BCRL).
Methods: Patients with BCRL consulted to physical therapy to receive lymphedema treatment were included. Age, gender, body mass index matched healthy controls (HC) were included to identify differences. The transtheoretical model was used to determine exercise behavior. Physical activity level was assessed by the International Physical Activity Questionnaire-Short Form (IPAQ-SF). The exercise barriers and preferences of patients with BCRL were recorded using a checklist based on the previous studies.
Results: A total of 48 female patients with BCRL and 38 female HC participated in the study. Physical activity level was significantly lower in patients with BCRL when compared to HC (p ˂ 0.05). However, the number of participants who engaged in regular exercise was significantly higher in patients with BCRL than HC (33.2% vs 7.9%, p ˂ 0.05). The most common exercise barriers were fatigue (64.5%), having other responsibilities (60.4%), and weather-related factors (56.2%). Majority of the participants preferred to participate in a supervised (79.1%), structured (66.6%), combined-type (77.1%), and moderate intensity (79.1%) exercise program, and they preferred to be informed at the time of the cancer diagnosis (45.8%) by a physiotherapist (66.6%). Moreover, the most preferred exercise type was walking/jogging (66.6%).
Conclusion: The present study showed inadequate physical activity and exercise behavior in patients with BCRL. Supportive care interventions are needed to overcome barriers for patients with BCRL. Preferences of patients and exercise enjoyment should also be taken into consideration to increase the participation in exercises.
Compression Stocking With 100% Donning and Doffing Success: An Open Label Randomised Controlled Trial - click for abstract
Compression Stocking With 100% Donning and Doffing Success: An Open Label Randomised Controlled Trial
Caroline S Buset, Julia Fleischer, Reinhold Kluge, Nicole T Graf, Giovanni Mosti, Hugo Partsch, Corsin Seeli, Florian Anzengruber, Michaël Kockaert, Monika Hübner, Jürg Hafner. Eur J Vasc Endovasc Surg. 2020 Oct 28.
Background: Lymphedema results from inadequate lymphatic function causing swelling in subcutaneous tissues. Lymph is transported proximally through valved lymphatic channels and muscle contraction. The purpose of this study was to determine lymphatic function in nonambulatory patients with lower extremity neuromuscular disease.
Methods and Results: Our Lymphedema Program database of 700 patients was reviewed for nonambulatory patients with lower extremity neuromuscular disease. Patient age, gender, disease, body mass index (BMI), and lymphoscintigram result were recorded. Eight patients were included in the study: myelomeningocele (n = 6), spinal muscle atrophy type 2 (n = 1), Charcot Marie Tooth (n = 1). Patient ages were between 15 and 36 years; five were female. BMI range for patients without swelling or a normal lymphoscintigram (n = 4) was 22-27. Four subjects with lymphatic dysfunction by lymphoscintigram all were obese (BMI 36-74; p = 0.03).
Conclusions: Nonambulatory patients with lower extremity neuromuscular dysfunction and swelling can exhibit normal lymphatic function. Obesity is associated with abnormal lymphoscintigram result and lymphedema in this patient population. Individuals should be advised to maintain a normal BMI.
The Effects of Clinical and Home-based Physiotherapy Programs in Secondary Head and Neck Lymphedemal - click for abstrac
The Effects of Clinical and Home-based Physiotherapy Programs in Secondary Head and Neck Lymphedema
Kadirhan Ozdemir, Ilke Keser, Mehmet Duzlu, Ozge P Erpolat, Uluc Saranli, Hakan Tutar. Laryngoscope. 2020 Oct 28.
Objectives/hypothesis: To determine the effects of complex decongestive physiotherapy (CDP) and home programs on external lymphedema, staging of lymphedema, fibrosis, and three-dimensional (3D) surface scanning and volume evaluation in head and neck lymphedema.
Study design: A prospective randomized controlled study.
Methods: Twenty-one patients were randomly divided into three groups: CDP (n:7), home program (n:7), and control (n:7). Assessment methods were applied at baseline and 4 weeks later for all groups. MD. Anderson Cancer Center Head and Neck Lymphedema Protocol was implemented to evaluate head and neck external lymphedema, staging of lymphedema, and fibrosis. A 3D scanner and a software were used to determine and calculate the volume of the head and neck region via 3D surface scanning. Head and neck external lymphedema and fibrosis assessment criteria were performed to evaluate visible soft tissue edema and the degree of stiffness.
Results: The severity and volume of lymphedema decreased in the CDP program group (P < .05). Besides, external lymphedema and fibrosis at submental region were decreased in both CDP program and home program groups (P < .05). Conclusions: While the benefits of home program are limited, a CDP program may be more effective in the management of lymphedema and fibrosis in patients diagnosed with head and neck cancer.
Intensive Treatment of Lower-Limb Lymphedema and Variations in Volume Before and After: A Follow-Up
Jose Maria Pereira de Godoy, Maria de Fatima Guerreiro Godoy, Stelamarys Barufi, Henrique Jose Pereira de Godoy. Cureus. 2020 Oct 1;12(10):e10756
