Hot of the Press August 2021

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

Pathophysiology of the Lymphatic System in Patients With Heart Failure: JACC State-of-the-Art Review - click for abstract

Pathophysiology of the Lymphatic System in Patients With Heart Failure: JACC State-of-the-Art Review
Maxim Itkin, Stanley G. Rockson, Daniel Burkhoff. J Am Coll Cardiol. 2021 Jul 20;78(3):278-290

The removal of interstitial fluid from the tissues is performed exclusively by the lymphatic system. Tissue edema in congestive heart failure occurs only when the lymphatic system fails or is overrun by fluid leaving the vascular space across the wall of the capillaries into the interstitial space. This process is driven by Starling forces determined by hydrostatic and osmotic pressures and organ-specific capillary permeabilities to proteins of different sizes. In this review, we summarize current knowledge of the generation of lymph in different organs, the mechanics by which lymph is returned to the circulation, and the consequences of the inadequacy of lymph flow. We review recent advances in imaging techniques that have allowed for new research, diagnostic, and therapeutic approaches to the lymphatic system. Finally, we review how efforts to increase lymph flow have demonstrated potential as a viable therapeutic approach for refractory heart failure.

Cellulitis Is Associated with Severe Breast Cancer-Related Lymphedema: An Observational Study of Tissue Composition - click for abstract

Cellulitis Is Associated with Severe Breast Cancer-Related Lymphedema: An Observational Study of Tissue Composition

Mads Gustaf Jørgensen, Anne Pernille Hermann, Anette Riis Madsen, Steffanie Christensen, Kim Gordon Ingwersen, Jørn Bo Thomsen, Jens Ahm Sørensen. Cancers (Basel). 2021 Jul 17;13(14):3584.
Cellulitis is a common complication in Breast Cancer-Related Lymphedema (BCRL). The excess amount of fat and lean mass in BCRL is a vital factor in patient stratification, prognosis, and treatments. However, it is not known whether cellulitis is associated with the excess fat and lean mass in BCRL. Therefore, this prospective observational study was designed to fundamentally understand the heterogonous biocomposition of BCRL. For this study, we consecutively enrolled 206 patients with unilateral BCRL between January 2019 and February 2020. All patients underwent Dual-Energy X-Ray Absorptiometry scans, bioimpedance spectroscopy, indocyanine green lymphangiography comprehensive history of potential risk factors, and a clinical exam. Multivariate linear and beta regression models were used to determine the strength of association and margins effect. Sixty-nine patients (33%) had at least one previous episode of cellulitis. Notably, a previous episode of cellulitis was associated with 20 percentage points more excess fat and 10 percentage points more excess lean mass compared to patients without cellulitis (p < 0.05). Moreover, each 1 increase in the patients BMI was associated with a 0.03 unit increase in the fat mass proportion of the lymphedema arm. Cellulitis was associated with more excess fat and lean arm mass in BCRL. In addition, patients BMI affect the proportion of fat mass in the arm.

The effects of lower body compression on left ventricular rotational mechanics in lymphoedema (from the MAGYAR-Path Study) - click for abstract

The effects of lower body compression on left ventricular rotational mechanics in lymphoedema (from the MAGYAR-Path Study)

Attila Nemes, Árpád Kormányos, Péter Domsik, Anita Kalapos, Lajos Kemény, Győző Szolnoky. ESC Heart Fail. 2021 Jul 20.
AIMS: Lower body half compression of bilateral secondary leg lymphoedema (LE) without relevant cardiac insufficiency gives rise to whether external leg compression may influence left ventricular (LV) function. Patients with LE were subjected to baseline two-dimensional transthoracic echocardiography (2DTTE) for general assessment then three-dimensional speckle-tracking echocardiography (3DSTE) before and 1 h after lower body half external compression for LV torsion analysis.
METHODS AND RESULTS: Baseline 2DTTE was performed in the cohort of 25 LE patients, and the results were compared with those of age- and gender-matched 52 healthy controls (mean age: 47.8 ± 12.8 vs. 40.7 ± 14.0 years, 24 women/1 man vs. 49 women/3 men, respectively). 3DSTE was conducted for the assessment of LV rotational mechanics where apical (AR), and basal rotations (BR) were measured before and 1 h after the use of compression class 2 (ccl 2) flat-knitted medical compression pantyhoses (pressure range: 23-32 mmHg). 2DTTE showed significantly larger LV end-diastolic volume and ejection fraction among LE patients compared with control subjects (108.3 ± 20.1 vs. 98.5 ± 21.7 mL, 69.8 ± 4.8 vs. 65.5 ± 4.3%, respectively) and notably smaller LV end-systolic diameter and posterior wall thickness (28.9 ± 3.5 vs. 31.2 ± 3.4 mm, 8.1 ± 1.0 vs. 9.0 ± 1.7 mm, respectively). The results of 20 patients with LE were considered in 3DSTE examinations due to the drop-out of five probands with technical failures. The data of four LE patients showing significant LV rotational abnormalities were managed separately, and the rotational parameters of the remaining sixteen patients did not differ significantly from those of matched controls except significant reduction of LV BR following the application of medical compression stockings (MCS) (-2.70 ± 1.26 degrees after 1 h use of pantyhose in patient group vs. -4.28 ± 2.18 degrees of the control group; P < 0.05).
CONCLUSIONS: The application of compression pantyhoses moderately but significantly decreased LV BR without a remarkable impact on twisting mechanism in LE patients in the absence of LV rotational abnormalities.

Vascular and lymphatic abnormalities - click for abstract

Vascular and lymphatic abnormalities

Adipocytes are larger in lymphedematous extremities than in controls

Jenny Zhang, Mattias Hoffner, Håkan Brorson. J Plast Surg Hand Surg. 2021 Aug 2:1-8.

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Prevalence and Risk Factors

Breast cancer-related lymphedema and its treatment: how big is the financial impact? - click for abstract

Breast cancer-related lymphedema and its treatment: how big is the financial impact?

Tessa De Vrieze1,2 & Nick Gebruers 2,3 & Ines Nevelsteen4 & Wiebren A. A. Tjalma3,5 & Sarah Thomis6 &
An De Groef1,2 & Lore Dams1,2 & Vincent Haenen1,2 & Nele Devoogdt1,6. Supportive Care in Cancer (2021) 29:3801–3813.

Purpose Decongestive lymphatic treatment (DLT) is still the gold standard for treatment of breast cancer-related lymphedema (BCRL). With up to 17% of the patients treated for breast cancer developing BCRL, this morbidity imposes a tremendous financial burden for patients and society. Knowledge about this economic burden related to BCRL and its conservative treatment in a European setting is lacking. The aim of this prospective, longitudinal cohort study was to estimate the direct healthcare costs related to BCRL and its treatment in a European setting.

Methods Patients with BCRL were treated with DLT consisting of an intensive treatment phase of 3 weeks, followed by a maintenance treatment phase of 6 months. Additionally, the follow-up period comprised 6 months. During these 3 weeks and 12 months, all direct costs associated with the treatment of BCRL and its sequelae were documented through billing prices and a self-developed questionnaire which was administered after the intensive treatment phase, and subsequently 3-monthly during the entire period.

Results A total of 194 patients were enrolled in this study. Of these, 17% (n = 32) showed lymphedema stage I, 56% (n = 109) had lymphedema stage IIa, and 27% (n = 53) had lymphedema stage IIb. Total direct healthcare costs per patient were €2248.93 on average during the entire period of 3 weeks of intensive treatments and 12 months of maintenance decongestive therapy. Within these mean direct costs, €1803.35 (80%) was accounted for statutory health insurances, and €445.58 (20%) was out-of-pocket expenses for patients.

Conclusion This study is one of the first standardized high-quality health economic analyses of BRCL treatment in Europe. The present study indicates that the price tag of BCRL treatment in Belgium is high not only for the health insurance but also for the patients.

Drug-induced peripheral oedema: An aetiology-based review - click for abstract

Drug-induced peripheral oedema: An aetiology-based review

Bérenger Largeau1, Jean-Luc Cracowski2, Céline Lengellé1, Bénédicte Sautenet3,4, Annie-Pierre Jonville-Béra1, Br J Clin Pharmacol. 2021;87:3043–3055.

Many drugs are responsible, through different mechanisms, for peripheral oedema. Severity is highly variable, ranging from slight oedema of the lower limbs to anasarca pictures as in the capillary leak syndrome. Although most often noninflammatory and bilateral, some drugs are associated with peripheral oedema that is readily erythematous (eg, pemetrexed) or unilateral (eg, sirolimus). Thus, drug-induced peripheral oedema is underrecognized and misdiagnosed, frequently leading to a prescribing cascade. Four main mechanisms are involved, namely precapillary arteriolar vasodilation (vasodilatory oedema), sodium/water retention (renal oedema), lymphatic insufficiency (lymphedema) and increased capillary permeability (permeability oedema). The
underlying mechanism has significant impact on treatment efficacy. The purpose of this review is to provide a comprehensive analysis of the main causative drugs by illustrating each pathophysiological mechanism and their management through an example of a drug.

Early side effects of radiation treatment for head and neck cancer - click for abstract

Early side effects of radiation treatment for head and neck cancer

I. Brook. Cancer/Radiothérapie 25 (2021) 507–513

Purpose of this review of medical literature is to present the immediate side effects of radiation therapy for head and neck cancer and their treatment. The likelihood and severity of these immediate side effects depends on a number of factors, including the total dose of radiation delivered, over what time it was delivered and what parts of the head and neck received radiation. Early side effects include: inflammation of the oropharyngeal mucosa (mucositis), painful swallowing (odynophagia), difficulty swallowing (dysphagia), hoarseness, lack of saliva (xerostomia), orofacial pain, laryngeal radionecrosis, dermatitis, hair loss, nausea, vomiting, inadequate nutrition and hydration, and weight loss. These complications can interfere with, and delay treatment. Most of these side effects generally dissipate over time. In conclusion, radiation treatment for the head and neck cancer causes significant early side effects. Many of these side effects present difficult challenges to the patients. Their recognition and treatment can significantly improve the patients’ health, long-term survival and quality of life. The review provides information that can assist head and cancer survivors deal with radiation side effects.

Influence of age and lymphedema on the postural balance of women undergoing breast cancer treatment - click for abstract

Influence of age and lymphedema on the postural balance of women undergoing breast cancer treatment

Cristina Faustino Cuviena , Carla Silva Perez , Victoria Carrer Nardo , Lais Mara Siqueira das Neves , Flavia Belavenuto Rangon , Elaine Caldeira de Oliveira Guirro *.Journal of Bodywork & Movement Therapies 27 (2021) 307e313.

Introduction: Breast cancer affects women of different ages, and comorbidities resulting from treatment can affect postural stability. The study aimed to evaluate the influence of age and lymphedema on the postural balance of women undergoing breast cancer treatment.

Methods: The study included 77 women undergoing breast cancer treatment, divided into different groups: 37 young adult women divided into 17 with lymphedema (GYL) and 20 young adults without lymphedema (GY); 40 elderly women, 20 elderly women with lymphedema (GEL) and 20 elderly women without lymphedema (GE). Mini Balance Evaluation Systems Test (Mini BESTest) and Falls Efficacy Scale – International (FES-I) were used.

Results: Mini BESTest and FES-I between the groups showed that GE and GEL had a significant difference to GY. Mini BESTest Total and Time Up and Go TUG-Double Task showed that GE has a significant difference to GYL, with GE and GEL having lower scores. Moderate negative correlation in the GEL between FES-I and Mini BESTest. In the age correlation between the Mini BESTest, FES-I, TUG, and double task TUG, a moderate positive correlation was observed for TUG. GEL showed a moderate positive correlation for FES-I and double-task TUG, strong for TUG, and moderate negative correlation with Mini BESTest. Correlation of the volume difference between the limb affected and not affected by lymphedema and the FES-I, Mini BESTest, TUG, and TUG double task, GYL showed moderate negative correlation for TUG.

Conclusion: Age and lymphedema influenced the dynamic postural balance of women undergoing breast cancer treatment

The Effects of Obesity on Lymphatic Pain and Swelling in Breast Cancer Patients - click for abstract

The Effects of Obesity on Lymphatic Pain and Swelling in Breast Cancer Patients

Mei Rosemary Fu 1,† , Deborah Axelrod 2,†, Amber Guth 2, Melissa L. McTernan 3, Jeanna M. Qiu 4, Zhuzhu Zhou 3, Eunjung Ko 5, Cherlie Magny-Normilus 6, Joan Scagliola 7 and Yao Wang 8. Biomedicines 2021, 9, 818.

Background: Lymphatic pain and swelling due to lymph fluid accumulation are the most common and debilitating long-term adverse effects of cancer treatment. This study aimed to quantify the effects of obesity on lymphatic pain, arm, and truncal swelling.

Methods: A sample of 554 breast cancer patients were enrolled in the study. Body mass index (BMI), body fat
percentage, and body fat mass were measured using a bioimpedance device. Obesity was defined as a BMI ≥ 30 kg/m2. The Breast Cancer and Lymphedema Symptom Experience Index was used to measure lymphatic pain, arm, and truncal swelling. Multivariable logistic regression models were used to estimate the odds ratio (OR) with 95% confidence interval (CI) to quantify the effects of obesity.

Results: Controlling for clinical and demographic characteristics as well as body fat percentage, obesity had the greatest effects on lymphatic pain (OR 3.49, 95% CI 1.87–6.50; p < 0.001) and arm swelling (OR 3.98, 95% CI 1.82–4.43; p < 0.001). Conclusions: Obesity is a significant risk factor for lymphatic pain and arm swelling in breast cancer patients. Obesity, lymphatic pain, and swelling are inflammatory conditions. Future study should explore the inflammatory pathways and understand the molecular mechanisms to find a cure.

Assessment

Accuracy, Sensitivity, and Specificity of the LLIS and ULL27 in Detecting Breast Cancer-Related Lymphedema - click for abstract

Accuracy, Sensitivity, and Specificity of the LLIS and ULL27 in Detecting Breast Cancer-Related Lymphedema

Michelle Coriddi, Leslie Kim, Leslie McGrath, Elizabeth Encarnacion, Nicholas Brereton, Yin Shen, Andrea V Barrio, Babak Mehrara, Joseph H Dayan. Ann Surg Oncol. 2021 Jul 15. doi: 10.1245/s10434-021-10469-1.
INTRODUCTION: Breast cancer-related lymphedema occurs in up to 30% of women following axillary lymph node dissection (ALND) and less commonly following sentinel lymph node biopsy. To quantify disability in these patients, patient-reported outcome measures (PROMs) have proven useful; however, given the overlap of symptoms between ALND and lymphedema, examination of their accuracy, sensitivity, and specificity in detecting lymphedema in breast cancer patients undergoing ALND is needed.
METHODS: The Lymphedema Life Impact Scale (LLIS) and the Upper Limb Lymphedema 27 scale (ULL27) were administered to patients who had undergone ALND at least 2 years prior and either did or did not develop lymphedema. Survey responses and the degree of disability were compared to generate receiver operator characteristic (ROC) curves, and the sensitivity and specificity of PROMs to diagnose lymphedema were analyzed.
RESULTS: Both PROMs were highly accurate, sensitive, and specific for detecting lymphedema. The LLIS had an accuracy of 97%, sensitivity of 100%, and specificity of 84.8% at a cutoff of ≥ 5.88 overall percent impairment score (higher scores indicate worse disability). The ULL27 had an accuracy of 93%, sensitivity of 88.6%, and specificity of 90.9% at a cutoff of ≤ 83.3 global score (lower scores indicate worse disability).
CONCLUSIONS: The LLIS and the ULL27 appear to be highly specific for lymphedema and capable of differentiating it from symptoms resulting from ALND alone. Our findings suggest that use of these questionnaires with a threshold may be effective for diagnosing lymphedema, potentially reducing the need for frequent clinic visits and time-consuming measurements

Lived Experiences for Supportive Care Needs of Women with Breast Cancer-Related Lymphedema: A Phenomenological Study - click for abstract

Lived Experiences for Supportive Care Needs of Women with Breast Cancer-Related Lymphedema: A Phenomenological Study
Ayşe Arikan Dönmez, PhD, RN1 , Nilgün Kuru Alici, PhD, RN1 , and Pınar Borman, MD1,2.Clinical Nursing Research 2021, Vol. 30(6) 799–808.
This descriptive phenomenological study was conducted to explore the lived experiences for supportive care needs of women with breast cancer-related lymphedema. Purposive sampling was used to recruit participants. In-depth, semi-structured interviews were conducted to collect data. Thematic analysis method was used for data analysis. Data saturation was achieved after interviewing 19 participants. The study was divided into four main themes and nine subthemes: physical (caused by difficulties in performing household chores, limitations in performing self-care activities, and challenges in shopping), psychosocial (being addicted to someone else in daily life, uncertainty about the future, social, and religious support), healthcare systems and information (attention from healthcare professionals, education and lifestyle advices, and access to healthcare sources), and financial supportive care needs. Women experience various SCNs in their daily lives. Provision of supportive care from both family members or others and healthcare professionals could ease the daily lives, improve physical, and psychosocial well-being.

Assessment of local tissue water in breasts following breast reconstruction with an expander prosthesis or DIEP flap

Linda Tallroth, Håkan Brorson, Nathalie Mobargha, Patrik Velander, Stina Klasson, Magnus Becker. J Plast Surg Hand Surg. 2021 Aug 3:1-7.

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Management Strategies

Exercising and Compression Mechanism in the Treatment of Lymphedema - click for abstract

Exercising and Compression Mechanism in the Treatment of Lymphedema

Stelamarys Barufi, Henrique Jose Pereira de Godoy, Jose Maria Pereira de Godoy, Maria de Fatima Guerreiro Godoy. Cureus. 2021 Jul 2;13(7).
AIM: The aim of this study was to evaluate the effect of adjustments to a compression stocking on reductions in leg volume during walking in patients with lymphedema.
METHOD: Fourteen women and three men suffering from leg lymphedema with ages between 21 and 68 years old (mean 45.68 years) were randomly enrolled in this study. Evaluations were made by volumetry before and after each session of controlled walking. Patients were subjected to three one-hour sessions of walking slowly on the flat ground monitored by a professional. For the first session, the patients used a well-adjusted cotton-polyester compression stocking, for the second they used a badly adjusted compression stocking made of the same fabric, and for the third, no compression garment was used. The Kruskal-Wallis test was used for statistical analysis.
RESULTS: On comparing the volume before and after walking for one hour with the well-adjusted cotton-polyester compression stocking, there was a mean reduction of 46.2 mL ± 66.95 mL (p-value < 0.02) in the volume of the lymphedema. In the one-hour session of walking without any compression, the volume of the leg increased by 74.4 mL ± 99.75 mL (p-value < 0.007). On walking with the compression stocking badly adjusted, there was a mean increase in the volume of 31.6 mL ± 46.9 mL (p-value < 0.14).
CONCLUSION: Walking is a type of muscle activity that can be transformed into a type of daily exercise when you are guided by how it is going to be performed. The exercise, in this study specifically, walking, with a strict control of speed and time of realization using a compression mechanism is well adjusted to the volume of the limb and surely effective in reducing edema

American Society of Breast Surgeons’ Practice Patterns for Patients at Risk and Affected by Breast Cancer-Related Lymphedema - click for abstract

American Society of Breast Surgeons’ Practice Patterns for Patients at Risk and Affected by Breast Cancer-Related Lymphedema
Sarah M DeSnyder, Min Yi, Francesco Boccardo, Sheldon Feldman, V Suzanne Klimberg, Mark Smith, Paul T R Thiruchelvam, Sarah McLaughlin. Ann Surg Oncol. 2021 Jul 31.
BACKGROUND: In 2017, the American Society of Breast Surgeons (ASBrS) published expert panel recommendations for patients at risk for breast cancer-related lymphedema (BCRL) and those affected by BCRL. This study sought to determine BCRL practice patterns.
METHODS: A survey was sent to 2975 ASBrS members. Questions evaluated members’ clinical practice type, practice duration, and familiarity with BCRL recommendations. Descriptive statistics, the chi-square test, and Fisher’s exact test were used.
RESULTS: Of the ASBrS members surveyed, 390 (13.1%) responded. Most of the breast surgeons (58.5%, 228/390) indicated unfamiliarity with recommendations. Nearly all respondents (98.7%, 385/390) educate at-risk patients. Most (60.2%, 234/389) instruct patients to avoid venipuncture, injection or blood pressure measurements in the at-risk arm, and 35.6% (138/388) recommend prophylactic compression sleeve use during air travel. Nearly all (97.7%, 380/389) encourage those at-risk to exercise, including resistance exercise (86.2%, 331/384). Most do not perform axillary reverse mapping (ARM) (67.9%, 264/389) or a lymphatic preventive healing approach (LYMPHA) (84.9%, 331/390). Most (76.1%, 296/389) screen at-risk patients for BCRL. The most frequently used screening tools include self-reported symptoms (81%, 255/315), circumferential tape measure (54%, 170/315) and bioimpedance spectroscopy (27.3%, 86/315). After a BCRL diagnosis, most (90%, 351/390) refer management to a lymphedema-certified physical therapist. For affected patients, nearly all encourage exercise (98.7%, 384/389). Many (49%, 191/390) refer affected patients for consideration of lymphovenous bypass or lymph node transfer.
CONCLUSION: Most respondents were unfamiliar with the ASBrS expert panel recommendations for patients at risk for BCRL and those affected by BCRL. Opportunities exist to increase awareness of best practices and to acquire ARM and LYMPHA technical expertise

Hemodynamic Responses in Lower Limb Lymphedema Patients Undergoing Physical Therapy - click for abstract

Hemodynamic Responses in Lower Limb Lymphedema Patients Undergoing Physical Therapy
Bianca Brix 1, Olivier White 2, Christian Ure 3, Gert Apich 3,4, Paul Simon 1, Andreas Roessler 1 and Nandu Goswami 1,*Biology 2021, 10, 642.
Background: Lymphedema arises due to a malfunction of the lymphatic system, leading to extensive tissue swelling. Complete decongestive therapy (CDT), which is a physical therapy lasting for 3 weeks and includes manual lymphatic drainages (MLD), leads to fluid mobilization and increases in plasma volume. Here, we investigated hemodynamic responses induced by these fluid shifts due to CDT and MLD.
Methods: Hemodynamic parameters were assessed continuously during a sit-to-stand test (5 min baseline, 5 min of standing, and 5 min of recovery). This intervention was repeated on days 1, 2, 7, 14, and 21 of CDT, before and after MLD. Volume regulatory hormones were assessed in plasma samples. Results: A total number of 13 patients took part in this investigation. Resting diastolic blood pressure significantly decreased over three weeks of CDT (p = 0.048). No changes in baseline values were shown due to MLD. However, MLD led to a significant decrease in
heart rate during orthostatic loading over all epochs on therapy day 14, as well as day 21. Volume regulatory hormones did not show changes over lymphedema therapy.
Conclusion: We did not observe any signs of orthostatic hypotension at rest, as well as during to CDT, indicating that lymphedema patients do not display an elevated risk of orthostatic intolerance. Although baseline hemodynamics were not affected, MLD has shown to have potential beneficial effects on hemodynamic responses to a sit-to-stand test in patients undergoing lymphedema therapy.
Simple Summary: Different stimuli can influence posture in daily life and, therefore, impose a risk of a solid balance during standing. To maintain this upright position, the capacity to recognize changes in posture and react appropriately is essential. The increased frequency of falls owing to postural hypotension, along with a lack of postural stability, is a serious problem not just in the elderly, but also different patient groups (e.g., cardiac patients, diabetic patients, or patients recovering from stroke). Similar changes in blood pressure regulation, as well as cardio-postural control, might occur in patients suffering from lymphedema due to differences in fluid volumes of the lower limbs. Lymphedema therapy could therefore affect hemodynamic responses during orthostatic loading (sit-to-stand test) due to the variable amounts of fluid in the lower limbs throughout therapy. To our knowledge, no previous study has ever longitudinally investigated the inter-relationship between lymphedema and hemodynamic responses and changes in volume regulatory hormones during orthostatic loading over three weeks of lymphedema treatment. We report here that lymphedema patients did not show signs of orthostatic hypotension, demonstrating that those patients do not seem to be at an increased risk for orthostatic intolerance and falls. However, lymphedema treatment showed to have a potential beneficial effect on cardiovascular responses during orthostatic challenge (sit-to-stand test) in lymphedema patients.

Treatment of Breast Cancer−Related Lymphedema Using Negative Pressure Massage: A Pilot Randomized Controlled Trial - click for abstract

Treatment of Breast Cancer−Related Lymphedema Using Negative Pressure Massage: A Pilot Randomized Controlled Trial
Riikka Lampinen, DPT,a Jeannette Q. Lee, PhD,b Janella Leano, DPT,a Christine Miaskowski, PhD,c Judy Mastick, MN,c Lisa Brinker, MA,a Kimberly Topp, PhD,d Betty Smoot, DPTScd. Archives of Physical Medicine and Rehabilitation 2021;102:1465−72.
Objective: To evaluate the efficacy of negative pressure massage treatment (NPMT) compared with manual lymphatic drainage (MLD) in women with chronic breast cancer−related lymphedema (LE). We hypothesized that NPMT would result in greater improvements in LE and upper limb function.
Design: Pilot single-blinded randomized controlled trial.
Setting: Health sciences university.
Participants: Of 64 women screened, 28 met eligibility requirements (ie, >18y of age; completed active treatment for breast cancer; had unilateral arm LE for ≥1y; were not receiving LE care; had stable LE) and were randomized to the NPMT (n=15) and control groups (n=13).
Interventions: The intervention group received NPMT and the control group received MLD; both received twelve 60-minute sessions over 4- 6 weeks.
Main Outcome Measures: Bioimpedance (lymphedema index [L-Dex] units]), limb volume (mL) calculated from limb circumference, and Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH) score.
Results: Outcomes were analyzed for 28 women. Compared to the MLD group, the NPMT group demonstrated greater improvement with a large effect size in L-Dex scores (P=.001; standardized mean difference [SMD]=1.15; 95% confidence interval, 1.96 to 0.35) and interlimb volume differences (P=.038; SMD=0.83; 95% confidence interval, 1.60 to 0.05). Differences in DASH scores were not statistically significant (P=.067).
Conclusions: Compared to MLD, treatment with NPMT resulted in greater improvement in L-Dex scores and interlimb volume differences in women with a duration of unilateral upper limb LE of >1 year. Our findings need to be confirmed in a larger randomized controlled trial.

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 Kabak1 & Ceren Gursen1 & Ayca Aytar2 & Turkan Akbayrak1 & Tulin Duger 1. Supportive Care in Cancer (2021) 29:3593–3602.
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.