Hot off the Press April 2022

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

Drug-Related Lymphedema: Mysteries, Mechanisms, and Potential Therapies

Soumiya Pal, Jenat Rahman, Shengyu Mu, Nancy J Rusch, Amanda J Stolarz

Front Pharmacol. 2022 Mar 4;13:850586.

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Classification of superficial lymphatic pathways in the upper extremity and incidence of lymphatic obstruction according to the lymphatic pathways in patients with unilateral upper extremity lymphedema - click for abstract

Kyong-Je Woo, Mi Kyung Lee, Ik Hyun Seong, Jin-Woo Park. J Plast Reconstr Aesthet Surg. 2022 Mar 2:S1748-6815(22)00133-4.

BACKGROUND: Indocyanine green (ICG) lymphography is frequently used in the diagnosis of lymphedema, as well as the planning of its surgical management, but the typical anatomy of the superficial lymphatic pathways is incompletely delineated. This study aims to evaluate the topographical anatomy of superficial lymphatic vessels of the upper extremity

METHODS: Sixty consecutive patients undergoing lymphaticovenular anastomosis for unilateral upper extremity lymphedema were selected. Lymphatic mapping was performed on the normal contralateral arm with ICG lymphography. A single upper arm reference line and two separate forearm reference lines (anterior and posterior) were drawn between anatomic landmarks. Lymphatic pathways were analyzed based on distances (cm) from the reference lines and were compared with those in lymphedema arms.

RESULTS: Mean age of the patients were 54.6 ± 8.4 years. Three lymphatic flow pathways were identified: anterior (100%), posterior (96.6%), and posterior-ulnar lymphatic (33.3%) vessels. The anterior and posterior lymphatic vessels ran along the anterior and posterior reference lines, respectively, on the forearm (within 2 cm) and medial to the upper arm reference line. In arms with lymphedema, the absence of lymphatic flow was most commonly observed in posterior lymphatics (29/59, 49%), followed by anterior (15/60, 25%) and posterior-ulnar lymphatics (1/20, 5%). Compared to normal arms, new lymphatic flow through posterior-ulnar lymphatics was observed in 34.5% of patients (10/29) in whom posterior lymphatics was completely obstructed.

CONCLUSIONS: Superficial lymphatic vessels can be classified into anterior, posterior, and posterior-ulnar lymphatic vessels. Posterior-ulnar lymphatic vessels might be least affected by lymphosclerosis in patients with lymphedema.

A scoping literature review of post-traumatic lymphedema: Where are we now? - click for abstract

A scoping literature review of post-traumatic lymphedema: Where are we now?

Christopher D Liao, Annet S Kuruvilla, Aleksandra Krajewski. J Plast Reconstr Aesthet Surg. 2022 Mar 7:S1748-6815(22)00143-7.

Post-traumatic lymphedema of the extremities is a significant source of morbidity largely unrecognized by practitioners. Given the unclear body of evidence on diagnosing and managing post-traumatic lymphedema, we performed a systematic scoping review of the literature for all reports on this topic in order to establish a benchmark for current knowledge, treatment modalities, patient outcomes, and future areas of research. After screening 733 titles and abstracts, 16 relevant articles were ultimately selected for analysis, producing 19 data entries. Study designs largely consisted of case reports and case series. The most frequently reported injuries included burns (n = 12), motor vehicle accidents (n = 7), degloving injuries (n = 6), and open tibial fractures (n = 4). A majority of patients were managed with compression therapy. Among patients pursuing surgical intervention, 15 underwent free tissue transfer and 2 underwent lymphovenous anastomoses. All patients had clinical improvement of their lymphedema. With clinical advances in our understanding of lymphedema and its medical and surgical treatments, it is critical that we identify patients in a timely manner to be able to provide them with the best medical care as well as identify areas of future research. We believe that patients with post-traumatic lymphedema are currently largely unrecognized and that collaboration as well as further research will allow for optimized outcomes in this population.

Prevalence and Risk Factors

Risk factors for lower extremity lymphedema after inguinal lymphadenectomy in melanoma patients: A retrospective cohort study - click for abstract

Risk factors for lower extremity lymphedema after inguinal lymphadenectomy in melanoma patients: A retrospective cohort study

Tianzhe Chen, Yue Lin, Qian Tan. Surg Open Sci. 2022 Feb 16;8:33-39

BACKGROUND: The aim of lymph node dissection for melanoma patients is to prevent metastasis. However, this procedure is accompanied by a long-term and impaired life-quality complication called extremity lymphedema. This condition involves long-term lower limb swelling, which causes discomfort and impaired function, and affects patients both physically and psychologically. Herein, we conducted a retrospective cohort study at a single center to investigate the risk factors associated with lower extremity lymphedema after inguinal lymphadenectomy.

MATERIALS AND METHODS: We identified 136 inguinal lymphadenectomy melanoma patients treated between January 2010 and January 2021. The patients’ demographic, clinical, and pathological data and postoperative outcomes were collected by electronic medical record review and patient follow-up. The patients’ postoperative outcomes were defined as lower extremity swelling and lower extremity lymphedema. Univariate and multivariate analyses were used to determine the independent predictors of lower extremity lymphedema.

RESULTS: The follow-up results from 85 melanoma patients who underwent inguinal lymphadenectomy were analyzed. Multivariate logistic regression analysis showed that number of lymph nodes removed ≥ 10 was the significant risk factor for postoperative lower extremity lymphedema (odds ratio = 6.468, P = .042, 95% confidence interval: 1.069 to 39.147). Moreover, 8 (100%) patients in the lower extremity lymphedema group and 32 (53.3%) patients in the normal group were female, which indicated that female patients might be more susceptible to postoperative lower extremity lymphedema (P = .012).

CONCLUSION: Our study found that number of inguinal lymph nodes removed ≥ 10 was associated with a significantly higher incidence of lower extremity lymphedema with a 6.5-fold increased risk in melanoma patients. Also, female patients were more likely to develop lower extremity lymphedema after inguinal lymphadenectomy.

Assessment

Tissue Dielectric Constant Differentials between Malignant and Benign Breast Tumors - click for abstract

Tissue Dielectric Constant Differentials between Malignant and Benign Breast Tumors

Harvey N. Mayrovitz, Daniel N Weingrad. Clin Breast Cancer. 2022 Feb 11:S1526-8209(22)00041-6.

INTRODUCTION: This study’s purpose was to characterize tissue dielectric constant (TDC) values of malignant and benign breast tumors and assess the potential utility of TDC differentials to help distinguish between malignant and benign tumors.

METHODS: Prior to their diagnostic biopsy, TDC was measured at 300 MHz in 59 women with previously detected breast tumors. TDC measurements were made by touching skin directly over the tumor and on the non-affected breast with a hand-held 22 mm diameter probe. Each measurement took less than 10 seconds. An inter-breast TDC ratio (RATIO) was calculated as the ratio of the tumor breast TDC value divided by the non-affected breast TDC value measured on the contralateral breast at a corresponding anatomical site. Absolute TDC values and RATIOS were compared for malignant and benign tumors based on post-measurement biopsy determinations.

RESULTS: Biopsy findings indicated tumors were malignant in 29 patients and benign in 30. Compared to the non-affected breast, malignant tumor TDC values were greater (P = .0002) whereas for benign tumors, there was no inter-breast difference (P = .256). No patient with a benign tumor exceeded a RATIO of 1.15 whereas 12 of the 29 patients with malignant tumors exceeded this threshold and tended to have larger volume tumors.

CONCLUSION: A tentative threshold RATIO of 1.15 may be discriminatory between malignant and benign tumors if the tumor is sufficiently large. Further research using a probe with a greater penetration depth is warranted to potentially increase discrimination.

What do lymphedema patients expect from a treatment and what do they achieve? A descriptive study - click for abstract

What do lymphedema patients expect from a treatment and what do they achieve? A descriptive study

Elif Duygu Yildiz, Yesim Bakar, Ilke Keser. J Vasc Nurs. 2022 Mar;40(1):59-65.

PURPOSE: Lymphedema is characterized by swelling and fibroadipose tissue deposition that is a physically, psychologically, and socially debilitating condition due to chronic and progressive nature of the disease. Treatment benefit evaluation from the patient’s perspective is important for medical decision-making. The aim of this study is to investigate important treatment goals and benefits of treatment from the patients’ perspective.

METHOD: Eighty-one patients with lymphedema, lipoedema, or lipolymphoedema who are currently treated or who underwent previous treatment were included in the study. Socio-demographic data was recorded. Important goals and benefit from treatment were assessed with Patients Needs Questionnaire and Patient Benefit Questionnaire which are sub-questionnaires of Patient Benefit Index-Lymphedema.

RESULTS: The most important expectation and needed item was “To find a clear diagnosis and therapy” (n:59, 72%). The least important item for the lymphedema patients was “To feel more attractive” (n:9, 11%). Most beneficial effect of treatment was “To have no fear that the disease will become worse” (n:37, 45.7%). “To have fewer out of pocket treatment expenses” was rated as the least beneficial effect of treatment (n:24, 29.6%).

CONCLUSIONS: It is important to identify patients’ needs and expectations. Patients should be referred for treatment according to their needs. The effectiveness of the treatment should be evaluated objectively. Patient education should be considered as a part of the effective treatment to teach patients how to control their lymphedema. A clear diagnosis and access to treatment should be ensured for lymphedema patients. Regulations for health insurance benefit coverage are needed to cover cost of compression garments.

Psychometric Properties of Quality of Life Questionnaires for Patients with Breast Cancer-Related Lymphedema: A Systematic Review - click for abstract

Psychometric Properties of Quality of Life Questionnaires for Patients with Breast Cancer-Related Lymphedema: A Systematic Review

Estu Meilani, Asfarina Zanudin, Nor Azlin Mohd Nordin. Int J Environ Res Public Health. 2022 Feb 22;19(5):2519.

BACKGROUNDS: Assessing quality of life (QoL) using a well-developed and validated questionnaire is an essential part of a breast cancer-related lymphedema (BCRL) treatment. However, a QoL questionnaire with the best psychometric properties is so far unknown. The aim of this systematic review is to evaluate the psychometric properties of the questionnaires measuring the QoL of patients with BCRL.

METHODS: A thorough search was performed to identify published studies in electronic databases such as Medline (via Ovid), EBSCOhost, PubMed, Scopus, and Web of Science, on 8 February 2022, by using search terms as follows: ‘quality of life’; ‘breast cancer’; ‘upper limb’; ‘lymphedema’; ‘questionnaire’; and ‘measurement properties.’ Two reviewers conducted article selection, data extraction, and quality assessment independently. The third reviewer helped solve any possible disagreements between the two reviewers. The COSMIN checklist and manual were used to assess the quality of included studies.

RESULTS: A total of nineteen articles with nine questionnaires were included and assessed using the COSMIN Risk of Bias checklist. Most studies only assessed content validity, structural validity, internal consistency, reliability, and construct validity. Lymph-ICF-UL showed the most ‘sufficient’ and ‘high’ quality of evidence ratings for its measurement properties.

CONCLUSION: The most appropriate questionnaire for use based on our assessment is Lymph-ICF-UL.

Relationship between Viscoelastic Properties of Tissues and Bioimpedance Spectroscopy in Breast-Cancer-Related Lymphedema - click for abstract

Relationship between Viscoelastic Properties of Tissues and Bioimpedance Spectroscopy in Breast-Cancer-Related Lymphedema

Alicja Naczk, Janusz Doś, Magdalena Górska-Doś, Robert Sibilski, Piotr Gramza, Ewa Gajewska, Mariusz Naczk

J Clin Med. 2022 Feb 26;11(5):1294

The aim of this study was to assess the relationship between the viscoelastic properties of tissues and breast-cancer-related lymphedema (BCRL). After a mastectomy, 46 females were allocated into a lymphedema group (L; n = 15, lymphedema occurred) and a control group (C; n = 31, lack of lymphedema). Bioimpedance spectroscopy was used to test BCRL. The mechanical properties of the tissues in both upper limbs were tested using myotonometry. In group L, tone, stiffness, relaxation time, and creep measured on the biceps brachii of the impaired limb significantly differed from the results on the unimpaired limb. In group C, the differences were not significant. Moreover, both tone and stiffness were inversely correlated with the level of lymphedema (r = -0.72 and r = -0.88, respectively), and both relaxation and creep were significantly related to the level of lymphedema (r = 0.71 and r = 0.59, respectively), when myotonometry was completed on the biceps brachii of the impaired limb in group L. The relationships were not significant in group C. Measurements of viscoelastic properties can provide useful information concerning lymphedema. Our findings suggest that significant correlations between selected mechanical properties of the tissues and BCRL can be used in BCRL detection and treatment.

The American venous forum, American vein and lymphatic society and the society for vascular medicine expert opinion consensus on lymphedema diagnosis and treatment

Fedor Lurie, Rafael D Malgor, Teresa Carman, Steven M Dean, Mark D Iafrati, Neil M Khilnani, Nicos Labropoulos, Thomas S Maldonado, Peter S. Mortimer, Thomas F O’Donnell, Joseph D Raffetto, Stanley G. Rockson, Antonios P Gasparis. Phlebology. 2022 Mar 8:2683555211053532.

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Association of Lower Extremity Lymphedema With Physical Functioning and Activities of Daily Living Among Older Survivors of Colorectal, Endometrial, and Ovarian Cancer

Xiaochen Zhang, Eric M McLaughlin, Jessica L Krok-Schoen, Michelle Naughton, Brittany M Bernardo, Andrea L. Cheville, Matthew Allison, Marcia Stefanick, Jennifer W Bea, Electra D. Paskett. JAMA Netw Open. 2022 Mar 1;5(3):e221671.

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Management Strategies

Compression therapy and heart failure: a scoping review of the existing evidence- click for abstract

Compression therapy and heart failure: a scoping review of the existing evidence

Garry Cooper-Stanton. Br J Community Nurs. 2022 Mar 2;27(3):128-134

The completion of a scoping review within the area of compression therapy and heart failure offers an insight into the present literature in this area, alongside offering the ability to connect this existing knowledge to chronic oedema/lymphoedema when both conditions co-exist. The evidence obtained included national agreed guidelines, consensus documents and existing primary/secondary research. The review identified existing evidence that suggests that the application of compression therapy in those with heart failure may be appropriate, but is dependent upon staging and stability. However, this needs to be contextualised against other co-morbidities, such as lymphoedema, which may impact upon the exact compression therapy and level applied. Further research within the area of heart failure in combination with chronic oedema/lymphoedema would expand the existing evidence base. This is set against a need for further consensus guidance to bridge the gap that exists within the literature.

Lymph-Venous Anastomosis for Breast Cancer-Related Lymphoedema after Docetaxel-Based Chemotherapy - click for abstract

Lymph-Venous Anastomosis for Breast Cancer-Related Lymphoedema after Docetaxel-Based Chemotherapy

Yuma Fuse, Ryo Karakawa, Tomoyuki Yano, Hidehiko Yoshimatsu. J Clin Med. 2022 Mar 4;11(5):1409.

Docetaxel-based chemotherapy, which is administered before or after axillary lymph node dissection (ALND) in breast cancer patients with positive axillary lymph nodes, is reported as an independent risk factor for development of breast cancer-related lymphoedema (BCRL). Severe hardening of the soft tissue, which is a typical manifestation of BCRL with a history of docetaxel-based chemotherapy, has been considered a contraindication for lymph-venous anastomosis (LVA). This study aimed to evaluate the efficacy of LVA for BCRL with a history of the use of docetaxel. Twenty-six consecutive BCRL patients who underwent LVA were reviewed retrospectively. All patients underwent ALND. Amongst 23 patients who had chemotherapy for breast cancer, docetaxel-based chemotherapy was administered in 12 patients. The postoperative change of the limb circumferences and the improvement of subjective symptoms were assessed. Overall, patients showed improvements of the limb circumferences at the wrist, the elbow, and 5 cm above and below the elbow. There were no statistical differences of the postoperative changes of the circumferences between the docetaxel-administered and non-administered groups (0.25% vs. 2.8% at 5 cm above the elbow (p = 0.23), -0.4% vs. 0.7% at 5 cm below the elbow (p = 0.56), and 2.5% vs. 2.5 % at the wrist (p = 0.82)). LVA is comparably effective for lymphedematous patients who had undergone docetaxel-based chemotherapy before or after ALND.

The Effect of Exercise for the Prevention and Treatment of Cancer-related Lymphedema: A Systematic Review with Meta-analysis- click for abstract

The Effect of Exercise for the Prevention and Treatment of Cancer-related Lymphedema: A Systematic Review with Meta-analysis

Sandra Christine Hayes, Ben Singh, Hildegard Reul-Hirche, Kira Bloomquist, Karin Johansson, Charlotta Jönsson, Melanie Louise Plinsinga. Med Sci Sports Exerc. 2022 Mar 22.

INTRODUCTION: The purpose of this systematic review and meta-analysis was to evaluate the effects of exercise on (i) the prevention of cancer-related lymphedema (CRL), and (ii) the treatment of CRL, lymphedema-associated symptoms, and other health outcomes among individuals with CRL.

METHODS: An electronic search was undertaken for exercise studies measuring lymphedema and involving individuals at risk of developing or with CRL. The Effective Public Health Practice Project Quality scale was used to assess study quality and overall quality of evidence was assessed using the GRADE approach. Meta-analyses were performed to evaluate effects of exercise on CRL incidence, existing CRL status, lymphedema-associated symptoms and health outcomes.

RESULTS: Twelve studies (n = 1,955; 75% moderate-high quality) and 36 studies (n = 1,741; 58% moderate-high quality) were included in the prevention and treatment aim, respectively. Relative risk of developing CRL for those in the exercise group compared with the non-exercise group was 0.90 (95% CI: 0.72, 1.13) overall, and 0.49 (95% CI: 0.28, 0.85) for those with 5 or more lymph nodes removed. For those with CRL in the exercise group, the standardised mean difference (SMD) pre- to post exercise of CRL was -0.11 (95% CI: -0.22, 0.01), and compared with usual care post-intervention the SMD was -0.10 (95% CI: -0.24, 0.04). Improvements post-intervention were observed for pain, upper-body function and strength, lower-body strength, fatigue and quality of life for those in the exercise group (SMD: 0.3-0.8; p < 0.05).

CONCLUSIONS: Findings support the application of exercise guidelines for the wider cancer population to those with or at risk of CRL. This includes promotion of aerobic and resistance exercise, and not just resistance exercise alone, as well as unsupervised exercise guided by symptom response.

The efficacy of Kinesio taping on lymphedema following head and neck cancer therapy: a randomized, double blind, sham-controlled trial - click for abstract

The efficacy of Kinesio taping on lymphedema following head and neck cancer therapy: a randomized, double blind, sham-controlled trial

Sevgi Atar, Yavuz Atar, Ugur Uygan, Seyma Görcin Karaketir, Tolgar Lütfi Kumral, Hüseyin Sari, Semih Karaketir, Ömer Kuru. Physiother Theory Pract. 2022 Mar 28:1-15.

OBJECTIVE: The aim was to investigate the effectiveness of Kinesio taping for lymphedema following head and neck cancer therapy and its effect on patient compliance and quality of life.

METHODS: A total of 66 patients with lymphedema following head and neck cancer therapy were randomly allocated to the therapeutic Kinesio taping group (n = 33) and the sham Kinesio taping group (n = 33). All participants received manual lymphatic drainage, Kinesio taping, and home exercises for the first four weeks, and only home exercises for the second four weeks. The tape measurements, a scale of external lymphedema, a scale of the internal lymphedema, and quality of life were evaluated in both groups. The perceived discomfort consisting of limitation of daily living activities, pain, tightness, stiffness, and heaviness were also recorded.

RESULTS: When the group x time effect was evaluated, it was observed that external lymphedema was significantly reduced in both groups according to neck and face composite measurements (p < .001). However, in these measurements, a significant difference was found between the groups in favor of the KT group (p = .001, p = .032, respectively). At the end of the study, there was no significant difference in terms of internal lymphedema in both groups (p = .860). The quality of life parameters such as global health status and swallowing were significantly better in the Kinesio taping group (p < .001). There was no significant difference in the parameters of perceived discomfort between the two groups (p = .282, p = .225, p = .090, p = .155, p = .183, respectively).

CONCLUSION: Kinesio taping is effective in tape measurements and positively affects the quality of life in lymphedema following head and neck cancer therapy.

Thyroid Hormone Ameliorates Lymphedema by Suppressing Adipogenesis in a Murine Lymphedema Model - click for abstract

Thyroid Hormone Ameliorates Lymphedema by Suppressing Adipogenesis in a Murine Lymphedema Model

Jaehoon Choi, Kanghee Lee, Junhyung Kim, Woonhyeok Jeong, Taehee Jo, Hyoun Wook Lee, Young Sook Park, Sang Woo Park. Lymphat Res Biol. 2022 Mar 24.

Exogenous supplementation of thyroid hormone could inhibit excessive fat deposition in lymphedema tissue by suppressing adipogenesis. Methods and Results: Cell viability, adipogenic differentiation, and mRNA expression were measured in 3T3-L1 preadipocytes treated with L-thyroxine. Twelve mice were divided into control and L-thyroxine groups. Two weeks after lymphedema was surgically induced, the experimental mice were fed L-thyroxine for 4 weeks. Tail volume and body weight were measured, and 6 weeks after the surgery, tail skin and subcutaneous tissue were harvested for histopathologic examination and protein isolation. In 3T3-L1 cells, treatment with 10-500 μM L-thyroxine did not affect cell viability. Eight days after induction of adipogenic differentiation, lipid accumulation decreased significantly in the 50 and 100 μM L-thyroxine groups (p < 0.001). mRNA levels of peroxisome proliferator-activated receptor γ (PPARγ), CCAAT/enhancer binding protein α (C/EBPα), and fatty acid-binding protein 4 (FABP4) decreased significantly in the 100 μM L-thyroxine group compared with the control group (p = 0.017). Lymphedema tails treated with L-thyroxine exhibited decreased volume (p = 0.028) and thickness of dermal and subcutaneous tissue (p = 0.01) and increased vascular endothelial growth factor-C protein expression (p = 0.017) compared with the control. Conclusion: Thyroid hormone therapy inhibits the adipogenesis of 3T3-L1 cells in vitro and decreases the volume of murine lymphedema tail in vivo. These findings suggest that thyroid hormone therapy could be used to treat lymphedema.

Effect of Manual Lymphatic Drainage on Breast Cancer-Related Postmastectomy Lymphedema: A Meta-analysis of Randomized Controlled Trials- click for abstract

Effect of Manual Lymphatic Drainage on Breast Cancer-Related Postmastectomy Lymphedema: A Meta-analysis of Randomized Controlled Trials

Jia Qiao, Li-Ning Yang, Yu-Han Kong, Xin Huang, Yi Li, Ding-Qun Bai. Cancer Nurs. 2022 Mar 24.

BACKGROUND: Manual lymphatic drainage (MLD) is widely used in the treatment of breast cancer-related postmastectomy lymphedema (BCRL). However, the therapeutic benefit of MLD on BCRL remains controversial.

OBJECTIVE: The aim of this study was to analyze the efficacy of MLD for BCRL.METHOD: Four electronic databases were systematically searched for trials comparing MLD and no MLD treatment as options for BCRL. Comparative treatment results included reduction of upper extremity limb volume with subgroup analysis by the number and duration of treatments.

RESULTS: A total of 457 patients were included in the analysis. There was no significant difference in the amount of upper extremity edema between the MLD treatment and control or no MLD groups (P = .11). However, when the treatment course was ≥20 sessions, there was a significant reduction in the upper extremity volume (P = .03). There was also a significant reduction in the upper extremity volume when treatment duration was >2 weeks (P = .03).

CONCLUSION: Manual lymphatic drainage treatment statistically did not reduce the upper extremity limb volume of BCRL, but upper extremity volume was reduced at statistically significant levels when treatment number were ≥20 sessions or the duration of treatment was >2 weeks.

IMPLICATION FOR PRACTICE: Reduction in upper limb volume is dependent on the number and duration of treatments. When treatment number were ≥20 sessions, or the duration of treatment was >2 weeks, reduction of upper limb volume was statistically achieved. Manual lymphatic drainage treatment can be clinically recommended to treat BCRL according to these parameters.

Can YouTube be used as an educational tool in lymphedema rehabilitation?

Okan Küçükakkaş, Buğra İnce. Arch Physiother. 2022 Mar 3;12(1):5. doi: 10.1186/s40945-022-00130-9

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The Post-thrombotic Syndrome-Prevention and Treatment: VAS-European Independent Foundation in Angiology/Vascular Medicine Position Paper

Benilde Cosmi, Agata Stanek, Matja Kozak, Paul W Wennberg, Raghu Kolluri, Marc Righini, Pavel Poredos, Michael Lichtenberg, Mariella Catalano, Sergio De Marchi, Katalin Farkas, Paolo Gresele, Peter Klein-Wegel, Gianfranco Lessiani, Peter Marschang, Zsolt Pecsvarady, Manlio Prior, Attila Puskas, Andrzej Szuba. Front Cardiovasc Med. 2022 Feb 24;9:762443.

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Effect of Supervised Resistance Training on Arm Volume, Quality of Life and Physical Perfomance Among Women at High Risk for Breast Cancer-Related Lymphedema: A Study Protocol for a Randomized Controlled Trial (STRONG-B)

Karol Ramírez-Parada, Maria Lopez-Garzon, Cesar Sanchez-Rojel, Militza Petric-Guajardo, Margarita Alfaro-Barra, Rodrigo Fernández-Verdejo, Alvaro Reyes-Ponce, Gina Merino-Pereira, Irene Cantarero-Villanueva. Front Oncol. 2022 Mar 1;12:850564

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